Mora Kathlyen, Dorrejo Xiomara M, Carreon Kimberly Mae, Butt Sadia
Rory Meyers College of Nursing, New York University, New York, New York.
J Am Assoc Nurse Pract. 2017 Dec;29(12):773-790. doi: 10.1002/2327-6924.12509. Epub 2017 Aug 28.
Chronically ill patients 65 and above have an increased risk of preventable readmission within 30 days of discharge from the hospital. The Transitional Care Model (TCM) introduced by Naylor and colleagues was implemented to improve the transition between hospital and home while decreasing readmissions. This article examines whether nurse practitioner (NP)- led TCM interventions as compared to standard care decrease hospital readmission rates in older adults.
A literature review was conducted from June 2016 to March 2017 using Cochrane Library, PubMed, Cumulative Index to Nursing and Health Literature (CINAHL) PLUS, Joanna Briggs Institute, and ProQuest Central to seek out the highest level of evidence. Search results were refined to focus on randomized control trials (RTCs) containing NP-led TCM interventions with older adults.
Synthesis of three RTCs, one meta-analysis, and four nonrandomized studies reviewed TCM interventions that included these interventions: follow-up phone calls post discharge, home visits, and handoff of information to the patient's primary care provider. These interventions, although not exclusively led by NPs, decreased hospital readmission rates.
NP-led TCM interventions have the potential to decrease readmissions, but the level of evidence is insufficiently high to allow for generalizability, warranting further study.
65岁及以上的慢性病患者在出院后30天内再次入院的可预防风险增加。由内勒及其同事引入的过渡性护理模式（TCM）旨在改善医院与家庭之间的过渡，同时降低再入院率。本文探讨与标准护理相比，由执业护士（NP）主导的TCM干预措施是否能降低老年人的医院再入院率。
于2016年6月至2017年3月进行文献综述，使用考克兰图书馆、PubMed、护理学与健康文献累积索引（CINAHL）PLUS、乔安娜·布里格斯研究所和ProQuest Central以寻找最高级别的证据。对搜索结果进行细化，聚焦于包含由NP主导的针对老年人的TCM干预措施的随机对照试验（RCT）。
对三项RCT、一项荟萃分析和四项非随机研究的综合分析回顾了TCM干预措施，这些干预措施包括：出院后随访电话、家访以及向患者初级保健提供者交接信息。这些干预措施虽然并非完全由NP主导，但降低了医院再入院率。
由NP主导的TCM干预措施有可能降低再入院率，但证据水平不够高，无法推广，需要进一步研究。
