J Korean Acad Nurs.  2015 Dec;45(6):919-927. 10.4040/jkan.2015.45.6.919.

Transitional Care for Older Adults with Chronic Illnesses as a Vulnerable Population: Theoretical Framework and Future Directions in Nursing

• Son YJ
• You MA

• KMID: 2363115
• DOI: http://doi.org/10.4040/jkan.2015.45.6.919

Abstract

PURPOSE
Effective transitional care is needed to improve the quality of life in older adult patients with chronic illness and avoid discontinuity of care and adverse events. The aim of this article is to provide an overview of the key features, broader implications, and the utility of Meleis' transition theory intended for the transitional care of older adults with chronic illnesses. We present the role of nurse in the context of transitional care and propose future directions to increase the quality of nursing care.
METHODS
The online databases Cumulative Index of Nursing and Allied Health Literature, MEDLINE, and Science Direct were searched for relevant literature published since 1970 along with textbooks regarding nursing theory.
RESULTS
An evaluation of the usefulness of transition theory based on transitional care in older adult patients with chronic illnesses is provided. Healthy transition should be the expected standard of nursing care for older adults across all healthcare settings.
CONCLUSION
Nurses need to contribute to the development of transitional care for vulnerable populations; however, transition theory needs to be enhanced through additional theoretical work and repeated evaluations of the applicability in areas of transitional care.

Keyword

Chronic illness; Nursing; Older adults; Transitional care; Transitional theory

MeSH Terms

Aged
Chronic Disease
Databases, Factual
Education, Nursing
Humans
Models, Theoretical
Nurse's Role
*Quality of Life
*Transitional Care

Reference

1. Ambrosio L, SenosiainGarcía JM, Riverol Fernández M, Anaut Bravo S, Diaz De Cerio Ayesa S, Ursua Sesma ME, et al. Living with chronic illness in adults: A concept analysis. J Clin Nurs. 2015; 24(17-18):2357–2367. DOI: 10.1111/jocn.12827.

2. Naylor M, Keating SA. Transitional care: Moving patients from one care setting to another. Am J Nurs. 2008; 108:9 Suppl. 58–63. DOI: 10.1097/01.NAJ.0000336420.34946.3a.

3. Levit K, Wier L, Stranges E, Ryan K, Elixhauser A. HCUP facts and figures: Statistics on hospital-based care in the United States, 2007. Rockville, MD: Agency for Healthcare Research and Quality;2009.

4. Allen J, Hutchinson AM, Brown R, Livingston PM. Quality care outcomes following transitional care interventions for older people from hospital to home: A systematic review. BMC Health Serv Res. 2014; 14:346. DOI: 10.1186/1472-6963-14-346.

5. Enderlin CA, McLeskey N, Rooker JL, Steinhauser C, D'Avolio D, Gusewelle R, et al. Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatr Nurs. 2013; 34(1):47–52. DOI: 10.1016/j.gerinurse.2012.08.003.

6. Adili F, Higgins I, Koch T. Older women and chronic illness: Transitioning and learning to live with diabetes. Action Res. 2013; 11(2):142–156. DOI: 10.1177/1476750313477157.

7. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med. 2007; 2(5):314–323. DOI: 10.1002/jhm.228.

8. Godfrey M, Townsend J. Older people in transition from illness to health: Trajectories of recovery. Qual Health Res. 2008; 18(7):939–951. DOI: 10.1177/1049732308318038.

9. American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Guiding principles for the care of older adults with multimorbidity: An approach for clinicians. J Am Geriatr Soc. 2012; 60(10):E1–E25. DOI: 10.1111/j.1532-5415.2012.04188.x.

10. Meleis AI, Sawyer LM, Im EO, Hilfinger Messias DK, Schumacher K. Experiencing transitions: An emerging middle-range theory. ANS Adv Nurs Sci. 2000; 23(1):12–28. DOI: 10.1097/00012272-200009000-00006.

11. Meleis AI. Transitions theory: Middle-range and situation-specific theories in nursing research and practice. New York, NY: Springer Publishing Company;2010.

12. Blum K, Sherman DW. Understanding the experience of caregivers: A focus on transitions. Semin Oncol Nurs. 2010; 26(4):243–258. DOI: 10.1016/j.soncn.2010.08.005.

13. Im EO. Transitions theory: A trajectory of theoretical development in nursing. Nurs Outlook. 2011; 59(5):278–285. DOI: 10.1016/j.outlook.2011.03.008.

14. Parry C, Mahoney E, Chalmers SA, Coleman EA. Assessing the quality of transitional care: Further applications of the care transitions measure. Med Care. 2008; 46(3):317–322. DOI: 10.1097/MLR.0b013e3181589bdc.

15. Coleman EA, Berenson RA. Lost in transition: Challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004; 141(7):533–536. DOI: 10.7326/0003-4819-141-7-200410050-00009.

16. Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med. 2006; 166(17):1822–1828. DOI: 10.1001/archinte.166.17.1822.

17. Society of Hospital Medicine. Overview project BOOST® implementation toolkit [Internet]. Philadelphia, PA: Author;2014. cited 2015 July 29. Available from: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/HTMLDisplay.cfm&CONTENTID=27659.

18. Jeong YH, Ko SJ, Kim EJ. A study on the effective chronic disease management. Report No.: Research Paper 2013-31-19. Sejong: Korea Institute for Health and Social Affairs;2013. 11.

19. Kanak MF, Titler M, Shever L, Fei Q, Dochterman J, Picone DM. The effects of hospitalization on multiple units. Appl Nurs Res. 2008; 21(1):15–22. DOI: 10.1016/j.apnr.2006.07.001.

20. Weiss ME, Piacentine LB, Lokken L, Ancona J, Archer J, Gresser S, et al. Perceived readiness for hospital discharge in adult medical-surgical patients. Clin Nurse Spec. 2007; 21(1):31–42.

21. Davis JD, Tremont G, Bishop DS, Fortinsky RH. A telephone-delivered psychosocial intervention improves dementia caregiver adjustment following nursing home placement. Int J Geriatr Psychiatry. 2011; 26(4):380–387. DOI: 10.1002/gps.2537.

22. Son YJ, Suh YO, Hong SK. Experiences on transfer of critically ill patients from intensive care units to general wards: Focus group interview on nurses' view. J Korean Acad Fundam Nurs. 2009; 16(1):92–102.

23. Son YJ. Development and effects of the collaborative transitional care program for continuity of care in patients transferred to general wards from ICUs. J Korean Clin Nurs Res. 2009; 15(3):143–155.

24. The Care Transitions Program. Health care services for improving quality and safety during care hand-offs [Internet]. Auroa, CO: Author;2015. cited 2015 July 29. Available from: http://caretransitions.org/.

25. Piraino E, Heckman G, Glenny C, Stolee P. Transitional care programs: Who is left behind? A systematic review. Int J Integr Care. 2012; 12:e132.

26. Preyde M, Brassard K. Evidence-based risk factors for adverse health outcomes in older patients after discharge home and assessment tools: A systematic review. J Evid Based Soc Work. 2011; 8(5):445–468. DOI: 10.1080/15433714.2011.542330.

27. Mistiaen P, Francke AL, Poot E. Interventions aimed at reducing problems in adult patients discharged from hospital to home: A systematic meta-review. BMC Health Serv Res. 2007; 7:47. DOI: 10.1186/1472-6963-7-47.

28. Geary CR, Schumacher KL. Care transitions: Integrating transition theory and complexity science concepts. ANS Adv Nurs Sci. 2012; 35(3):236–248. DOI: 10.1097/ANS.0b013e31826260a5.

29. Fex A, Flensner G, Ek AC, Söderhamn O. Health-illness transition among persons using advanced medical technology at home. Scand J Caring Sci. 2011; 25(2):253–261. DOI: 10.1111/j.1471-6712.2010.00820.x.

30. Laugaland K, Aase K, Barach P. Interventions to improve patient safety in transitional care-a review of the evidence. Work. 2012; 41:Suppl 1. 2915–2924. DOI: 10.3233/wor-2012-0544-2915.