This is a study of care transitions experienced by older adults with advanced chronic illness using complexity science as the conceptual framework. The purpose is to describe, from multiple perspectives, care transitions from hospital to a nursing home for skilled care and for the first 120 days following, including additional transitions that may occur.
Aims of the study are to describe care transitions from the perspectives of patients, informal caregivers, and health care providers;to explore trajectories i patient quality of life and symptoms related to health care utilization (e.g., ER visits and hospitl readmissions);and to better understand patterns in the complexity of care transitions through cross-case comparison including both the qualitative themes and the quantitative measures. This prospective, mixed methods study will use multiple case studies with an embedded quantitative strand and multiple sources of information including interview, observation, and medical records review. Research that encompasses both patient and health care provider perspectives is highly significant in this era of health care reform and patient-centered outcomes research. Research completed to date is narrow in focus: addressing only patient symptoms and quality of life or system variables, such as readmission. In addition, research on the transition from hospital to skilled nursing care is limited both in quantity and scope. This result in a view of care transitions that does not adequately inform research or practice. An in-depth description of patients'care transition experiences from multiple perspectives across time is needed. The tenets of complexity science have informed study design and methods including the prospective nature of the study, data collection from multiple sources, and the incorporation of both qualitative and quantitative data. This study will provide a rich description of each patiet and his or her transition(s). Included are qualitative descriptions of the patients', caregivers'ad HCPs'perspectives, with quantitative patient-focused measures (QoL and symptoms) and systems-based measures (ER visits and hospital readmissions). This design allows the capture of the complexity of transition as well as the array of events, both clinical and context-based, that affect the decision to transfer. This unprecedented view will inform the development of interventions to improve care and decrease unnecessary utilization. As a key component of pre-doctoral training at a research-intensive university, this study will lay the foundation for a carer as an academic nurse scientist during an era of major reform in the U.S. health care system. It synthesizes a focus on NINR's mission to advance the science of symptom management and quality of life in patients with advanced, life-limiting conditions with the national imperative to make the U.S. health care system more patient-centered.

Public Health Relevance

This study will provide an in-depth description of care transitions (e.g. leaving the hospital to a nursing home) from the perspective of older adults with complex health needs. This population is at-risk for negative transition outcomes, such as poorly managed symptoms, decreased quality of life, and high utilization of health care resources. Better understanding of patients'experiences will contribute to the design of new patient-oriented systems of care in the context of health care reform.

National Institute of Health (NIH)
National Institute of Nursing Research (NINR)
Predoctoral Individual National Research Service Award (F31)
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National Institute of Nursing Research Initial Review Group (NRRC)
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Banks, David
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University of Nebraska Medical Center
Schools of Nursing
United States
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Rolland, Yves; Resnick, Barbara; Katz, Paul R et al. (2014) Nursing home research: the first International Association of Gerontology and Geriatrics (IAGG) research conference. J Am Med Dir Assoc 15:313-25