If at First You Don't Succeed: Efforts to Improve Collaboration Between Nursing Homes and a Health System
From
Topics in Advanced Practice Nursing eJournal
Posted 09/01/2004
Virginia K. Lee, MSN, ANP; Cynthia J. Westley, RN-C, MSN, ANP-C; Kathleen Fletcher, RN, APRN, BC, GNP, FAAN
Introduction
Elderly patients aged 65 years and older account for 38% of hospital admissions and 42% of inpatient days of care.[1] Compared with younger persons, the elderly have longer and more frequent hospitalizations, with a greater severity of illness. They are often unable to return home safely because of diminished function and may require admission to long-term care for short-term rehabilitation or for an extended or final stay. Studies show that approximately 23% of elderly patients who are hospitalized go to another institution such as a skilled nursing facility, intermediate care facility, or other rehabilitation hospital upon discharge, and 11.6% are discharged home with home care services.[2]
Frequent readmissions to the hospital are also common because of complications, acute exacerbations of chronic illnesses, falls, or the development of new medical problems. This frequency of patient moves among settings underscores the need for careful communication and information sharing during these times of transition...
...This paper describes initial efforts in one community to address process issues and the quality of information shared during transitions in an effort to improve the quality of care provided to older adults and to build a greater sense of partnership between health settings...
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http://www.medscape.com/viewarticle/487323
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