Journal article

A transitional care service for elderly chronic disease patients at risk of readmission.

Caroline A Brand, Catherine T Jones, Adrian J Lowe, David A Nielsen, Carol A Roberts, Bellinda L King, Donald A Campbell

Aust Health Rev | Published : 2004


BACKGROUND: Multiple hospital admissions, especially those related to chronic disease, represent a particular challenge to the acute health care sector in Australia. OBJECTIVE: To determine whether a nurse-led chronic disease management model of transitional care reduced readmissions to acute care. DESIGN: A quasi-experimental controlled trial. SETTING: A large tertiary metropolitan teaching hospital. PARTICIPANTS: 166 general medical patients aged > or = 65 years with either a history of readmissions to acute care or multiple medical comorbidities. INTERVENTION: Implementation of a chronic disease management model of transitional care aimed at improving patient management and reducing readm..

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