ABSTRACT
For more than 15 years, our multidisciplinary research team has been testing evidence-based clinical interventions guided by the Quality Cost Model of APN Transitional Care (hereafter referred to as the APN Care Model). These interventions have been designed to improve the quality of care and outcomes of high risk cognitively intact older adults as they make the difficult transition from hospital to home. Findings from three NIH-funded randomized control trials (RCTs) have consistently demonstrated improved quality and reductions in hospital readmissions and health care costs among intervention patients compared to control patients receiving standard care (Naylor et aI., 1994; Naylor et aI., 1999; Naylor et aI., 2004). Recently, our team has begun to extend application of the APN Care Model to other high risk patient groups. With the support of the Alzheimer's Association, we have conducted pilot studies that have yielded important information about the unique health issues faced by cognitively impaired older adults and their caregivers during transitions from hospitals to home and suggested the value of interventions designed specifically to meet their needs (Naylor, Stephens, Bowles, & Bixby, 2005). Currently, with the support of the National Institute of Aging and Marian S. Ware Alzheimer's Program, our team is testing a
SIGNIFICANCE
Charlson, & Sax, 1986; Gutterman, Markowitz, Lewis, & Fillit, 1999; Hill et aI., 2002; Lyketsos, Sheppard, & Rabins, 2000; McCormick et al., 2001). Collectively, CI and chronic medical illnesses result in greater morbidity, increased preventable hospitalizations and poorer survival (Feil, Marmon, & Unutzer, 2003; Zuccala et aI., 2003). Investigators hypothesize that medical conditions may negativel y impact cognition and neurodegeneration (Bynum et aI., 2004; Doraiswamy, Leon, Cummings, Marin, & Neumann, 2002; Feil et aI., 2003; McCormick et aI., 1994; Zucca]a et aI., 2003). Conversely, CI among elders with other comorbid conditions may lead to inaccurate symptom reporting, delayed or inadequate treatment of the comorbid conditions and nonadherence with prescribed therapies (Doraiswamy et aI., 2002; McCormick et aI., 1994; Sloan, Trogdon, Curtis, & Schulman, 2004; Sullivan-Marx, 1994). When CI co-exists with depression (approximately 20% of cases), adherence with prescribed therapies, and thus outcomes, are especially poor (Feil et aI., 2003).
