Transitional Care Models for High-Need, High-Cost Adults in the United States: A Scoping Review and Gap Analysis.

Autor: Hewner S; Sharon Hewner, PhD, RN, FAAN, is a faculty in the Department of the Family, Community and Health Systems Science Department in the University at Buffalo School of Nursing. Her research focuses on implementing technology-supported care management interventions to improve transitional care for persons with social needs and multiple chronic conditions.; Chiahui Chen, MS, RN, FNP-BC, is a University at Buffalo School of Nursing PhD candidate. Her research interests are concerned with the development of a comprehensive understanding of end-of-life care in the intensive care unit and the improvement of nursing care to enhance the quality of end of life.; Linda Anderson, BSN, RN, is a PhD student in Sinclair School of Nursing at the University of Missouri-Columbia. Her doctoral research focuses on exploring functional status, health care experiences, and health-related quality of life in older women with chronic illness and disability.; Lana Pasek, EdM, MSN, ANP-BC, CCRN, CNRN, is a University at Buffalo Nursing doctoral student. She is an adult nurse practitioner with experience managing high-need, high-cost patients in a county hospital and an inner-city clinic. Her research interest is the development of patient-reported outcome measures for chronic diseases.; Amanda Anderson, MSN, MPA, RN, is a University at Buffalo Nursing doctoral student. Amanda develops care transitions programs utilizing nurses and telehealth, and she is a contributing editor for the American Journal of Nursing . Her research looks at gaps homeless patients face when transitioning between community-based and acute care institutions.; Lori Popejoy, PhD, RN, FAAN, is the Associate Dean for Innovation and Partnerships in Sinclair School of Nursing at the University of Missouri. She is a health system researcher focused on understanding the complex issues surrounding care to older adults across the continuum and implementation of evidence-based approaches to care coordination., Chen C; Sharon Hewner, PhD, RN, FAAN, is a faculty in the Department of the Family, Community and Health Systems Science Department in the University at Buffalo School of Nursing. Her research focuses on implementing technology-supported care management interventions to improve transitional care for persons with social needs and multiple chronic conditions.; Chiahui Chen, MS, RN, FNP-BC, is a University at Buffalo School of Nursing PhD candidate. Her research interests are concerned with the development of a comprehensive understanding of end-of-life care in the intensive care unit and the improvement of nursing care to enhance the quality of end of life.; Linda Anderson, BSN, RN, is a PhD student in Sinclair School of Nursing at the University of Missouri-Columbia. Her doctoral research focuses on exploring functional status, health care experiences, and health-related quality of life in older women with chronic illness and disability.; Lana Pasek, EdM, MSN, ANP-BC, CCRN, CNRN, is a University at Buffalo Nursing doctoral student. She is an adult nurse practitioner with experience managing high-need, high-cost patients in a county hospital and an inner-city clinic. Her research interest is the development of patient-reported outcome measures for chronic diseases.; Amanda Anderson, MSN, MPA, RN, is a University at Buffalo Nursing doctoral student. Amanda develops care transitions programs utilizing nurses and telehealth, and she is a contributing editor for the American Journal of Nursing . Her research looks at gaps homeless patients face when transitioning between community-based and acute care institutions.; Lori Popejoy, PhD, RN, FAAN, is the Associate Dean for Innovation and Partnerships in Sinclair School of Nursing at the University of Missouri. She is a health system researcher focused on understanding the complex issues surrounding care to older adults across the continuum and implementation of evidence-based approaches to care coordination., Anderson L; Sharon Hewner, PhD, RN, FAAN, is a faculty in the Department of the Family, Community and Health Systems Science Department in the University at Buffalo School of Nursing. Her research focuses on implementing technology-supported care management interventions to improve transitional care for persons with social needs and multiple chronic conditions.; Chiahui Chen, MS, RN, FNP-BC, is a University at Buffalo School of Nursing PhD candidate. Her research interests are concerned with the development of a comprehensive understanding of end-of-life care in the intensive care unit and the improvement of nursing care to enhance the quality of end of life.; Linda Anderson, BSN, RN, is a PhD student in Sinclair School of Nursing at the University of Missouri-Columbia. Her doctoral research focuses on exploring functional status, health care experiences, and health-related quality of life in older women with chronic illness and disability.; Lana Pasek, EdM, MSN, ANP-BC, CCRN, CNRN, is a University at Buffalo Nursing doctoral student. She is an adult nurse practitioner with experience managing high-need, high-cost patients in a county hospital and an inner-city clinic. Her research interest is the development of patient-reported outcome measures for chronic diseases.; Amanda Anderson, MSN, MPA, RN, is a University at Buffalo Nursing doctoral student. Amanda develops care transitions programs utilizing nurses and telehealth, and she is a contributing editor for the American Journal of Nursing . Her research looks at gaps homeless patients face when transitioning between community-based and acute care institutions.; Lori Popejoy, PhD, RN, FAAN, is the Associate Dean for Innovation and Partnerships in Sinclair School of Nursing at the University of Missouri. She is a health system researcher focused on understanding the complex issues surrounding care to older adults across the continuum and implementation of evidence-based approaches to care coordination., Pasek L; Sharon Hewner, PhD, RN, FAAN, is a faculty in the Department of the Family, Community and Health Systems Science Department in the University at Buffalo School of Nursing. Her research focuses on implementing technology-supported care management interventions to improve transitional care for persons with social needs and multiple chronic conditions.; Chiahui Chen, MS, RN, FNP-BC, is a University at Buffalo School of Nursing PhD candidate. Her research interests are concerned with the development of a comprehensive understanding of end-of-life care in the intensive care unit and the improvement of nursing care to enhance the quality of end of life.; Linda Anderson, BSN, RN, is a PhD student in Sinclair School of Nursing at the University of Missouri-Columbia. Her doctoral research focuses on exploring functional status, health care experiences, and health-related quality of life in older women with chronic illness and disability.; Lana Pasek, EdM, MSN, ANP-BC, CCRN, CNRN, is a University at Buffalo Nursing doctoral student. She is an adult nurse practitioner with experience managing high-need, high-cost patients in a county hospital and an inner-city clinic. Her research interest is the development of patient-reported outcome measures for chronic diseases.; Amanda Anderson, MSN, MPA, RN, is a University at Buffalo Nursing doctoral student. Amanda develops care transitions programs utilizing nurses and telehealth, and she is a contributing editor for the American Journal of Nursing . Her research looks at gaps homeless patients face when transitioning between community-based and acute care institutions.; Lori Popejoy, PhD, RN, FAAN, is the Associate Dean for Innovation and Partnerships in Sinclair School of Nursing at the University of Missouri. She is a health system researcher focused on understanding the complex issues surrounding care to older adults across the continuum and implementation of evidence-based approaches to care coordination., Anderson A; Sharon Hewner, PhD, RN, FAAN, is a faculty in the Department of the Family, Community and Health Systems Science Department in the University at Buffalo School of Nursing. Her research focuses on implementing technology-supported care management interventions to improve transitional care for persons with social needs and multiple chronic conditions.; Chiahui Chen, MS, RN, FNP-BC, is a University at Buffalo School of Nursing PhD candidate. Her research interests are concerned with the development of a comprehensive understanding of end-of-life care in the intensive care unit and the improvement of nursing care to enhance the quality of end of life.; Linda Anderson, BSN, RN, is a PhD student in Sinclair School of Nursing at the University of Missouri-Columbia. Her doctoral research focuses on exploring functional status, health care experiences, and health-related quality of life in older women with chronic illness and disability.; Lana Pasek, EdM, MSN, ANP-BC, CCRN, CNRN, is a University at Buffalo Nursing doctoral student. She is an adult nurse practitioner with experience managing high-need, high-cost patients in a county hospital and an inner-city clinic. Her research interest is the development of patient-reported outcome measures for chronic diseases.; Amanda Anderson, MSN, MPA, RN, is a University at Buffalo Nursing doctoral student. Amanda develops care transitions programs utilizing nurses and telehealth, and she is a contributing editor for the American Journal of Nursing . Her research looks at gaps homeless patients face when transitioning between community-based and acute care institutions.; Lori Popejoy, PhD, RN, FAAN, is the Associate Dean for Innovation and Partnerships in Sinclair School of Nursing at the University of Missouri. She is a health system researcher focused on understanding the complex issues surrounding care to older adults across the continuum and implementation of evidence-based approaches to care coordination., Popejoy L; Sharon Hewner, PhD, RN, FAAN, is a faculty in the Department of the Family, Community and Health Systems Science Department in the University at Buffalo School of Nursing. Her research focuses on implementing technology-supported care management interventions to improve transitional care for persons with social needs and multiple chronic conditions.; Chiahui Chen, MS, RN, FNP-BC, is a University at Buffalo School of Nursing PhD candidate. Her research interests are concerned with the development of a comprehensive understanding of end-of-life care in the intensive care unit and the improvement of nursing care to enhance the quality of end of life.; Linda Anderson, BSN, RN, is a PhD student in Sinclair School of Nursing at the University of Missouri-Columbia. Her doctoral research focuses on exploring functional status, health care experiences, and health-related quality of life in older women with chronic illness and disability.; Lana Pasek, EdM, MSN, ANP-BC, CCRN, CNRN, is a University at Buffalo Nursing doctoral student. She is an adult nurse practitioner with experience managing high-need, high-cost patients in a county hospital and an inner-city clinic. Her research interest is the development of patient-reported outcome measures for chronic diseases.; Amanda Anderson, MSN, MPA, RN, is a University at Buffalo Nursing doctoral student. Amanda develops care transitions programs utilizing nurses and telehealth, and she is a contributing editor for the American Journal of Nursing . Her research looks at gaps homeless patients face when transitioning between community-based and acute care institutions.; Lori Popejoy, PhD, RN, FAAN, is the Associate Dean for Innovation and Partnerships in Sinclair School of Nursing at the University of Missouri. She is a health system researcher focused on understanding the complex issues surrounding care to older adults across the continuum and implementation of evidence-based approaches to care coordination.

Publikováno v: Professional case management [Prof Case Manag] 2021 Mar-Apr 01; Vol. 26 (2), pp. 82-98.