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Transition Care

This trend offers new practice opportunities for acute care NPs.

It is well known that older adults have longer hospital stays and more rapid functional decline than younger patients, and that these problems are further complicated by contributory physical and cognitive impairments.1 The multiple comorbidities and complexities of the aging population require an interdisciplinary and collaborative approach that provides multipart transitions of care.

At the time of discharge, older patients have a strong reliance on family and community resources. The use of an acute care nurse practitioner (ACNP) on a medical service team can improve continuity and transitions of care. The University of California Medical Center in San Francisco developed a team that included ACNPs who worked collaboratively with hospitalists. These ACNPs admit, manage and provide input to community providers about hospital stays and potential discharge needs. The relationship that develops between the ACNP and community providers allows for an improved transition.2 Each ACNP in the program has specialized training in the management of patients with acute, chronic and critical illnesses in a variety of settings.

The graduate education of the ACNP develops expertise in the management and coordination of all services to improve the health of acutely ill patients. ACNPs practice in intensive care units, emergency departments and multi-practice clinics.3 The specialized education and training of the ACNP prepares them to manage acute processes and coordinate necessary services.

When patients are admitted to the hospital for acute conditions, the expertise of the ACNP contributes to the identification and resolution of medical issues.2 As these acute or critical issues are resolved, it is imperative to review and manage concomitant comorbidities. For all patients, discharge planning starts at the time of admission. But it is especially important with geriatric patients.


Models of Transition Care

The Transitional Care Model was introduced 18 years ago at the University of Pennsylvania in Philadelphia.4,5 It has since been refined to coordinate with current trends in healthcare. For example, older adults with chronic conditions are at risk for readmission and worsening of medical problems and therefore require heightened attention to transition care.

The model focuses on improving the care and outcomes of hospitalized patients and transitioning them effectively from hospital to home. Patients are seen within 24 hours of admission, home visits are made within 24 hours of discharge, and bimonthly visits are made during the second and third months after discharge. An ACNP is available via telephone throughout the process.4 Coleman's Care Transitions Interventions Model uses the concept of a transition coach.5 The transition coach meets with the patient during hospitalization, completes a home visit within 48 to 72 hours post discharge, and is available via telephone for 28 days post discharge.5

Both care transition models use advanced practice nurses. The master's-prepared nurse with clinical experience in acute care and advanced education is the ideal candidate to make the programs successful.

The Acute Care for Elders (ACE) Unit at Kennedy University Hospital-Stratford Division in Stratford, N.J., employs an ACNP to manage aging patients. The increasing complexity of comorbidities and social issues of the geriatric patient was the motivation to hire an ACNP with critical care and emergency nursing background. The ACNP has the education and experience to manage these complex issues. This nurse practitioner's experience and knowledge provide a more comprehensive medical management of these complex patients.

The ACNP role at Kennedy University Hospital is unique and combines the service-based advanced practice nurse and transition care advanced practice nurse into an all-inclusive provider. The ACNP medically co-manages patients who are admitted to the unit. Discharge planning and transitions of care begin at the time of admission.

The goals of the ACNP role are to reduce and manage polypharmacy, to prevent falls and delirium and to decrease readmissions. The ACNP also serves as a geriatric resource for nurses, medical and nursing students, and medical residents.

Acute care, primary care and family nurse practitioner students can benefit from a clinical rotation on an ACE unit. At Kennedy University Hospital, opportunities for a preceptorship are available with the ACNP or the medical director, who specializes in geriatrics. The multitude of acute and chronic conditions of the geriatric patient provides a vast learning experience. The prioritization and coordination of care are high-priority skills that can be learned on the ACE unit. This will provide the practitioner and patient with the tools and knowledge to promote positive patient outcomes.

The ACNP on the ACE unit also follows patients after discharge. Prior to discharge, the ACNP calls the family to provide education and updates and contacts the primary care provider to make follow-up appointments and provide updates on hospital course and discharge plans. Three days after discharge, follow-up phone calls are made to the patient to provide further verbal education or to assist with discharge needs. Effective and thorough transitions of care begin at the time of admission. The ACNP is available 5 days a week and is the healthcare team member who is contiguous throughout the patient's hospital stay, thus improving transition.


Patient Satisfaction and Clinical Outcomes

Several studies have demonstrated that patients are satisfied with the care provided by an ACNP.3 The integration of the ACNP onto the medical team has improved patient satisfaction and contributed to greater adherence to positive clinical outcomes. The ACNP is able to begin discharge planning or order rehabilitation services prior to physician evaluation.6 The unit-based ACNP has the potential to be the first point of contact for patient-related issues or emergencies.

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a new measurement tool for consumers to utilize when choosing a medical facility. The tool helps consumers identify the medical facilities with the best clinical outcomes. The intent of the HCAHPS initiative is to provide a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care.7 Healthcare facilities with a low score have the potential to lose patient populations. It can be hypothesized that ACNP involvement in the transition of care can potentially improve scores by reducing readmission rates and improving clinical outcomes.


Evolution Will Continue

The roles and responsibilities of healthcare providers evolve in response to clinical trends and needs. The role of the ACNP has been evolving since its inception. Studies have demonstrated that the nurse practitioner role is imperative to improved patient outcomes and satisfaction.5 The patients and the medical community alike will benefit from the inception of the ACNP in transitions of care.

The ACNP can fill the gap between hospital discharge and follow-up with the primary care provider. A continuous chain of communication is essential to deliver the best possible care using evidence-based practice. The ACNP role at Kennedy University Hospital has integrated the appropriate factors into a process for transitions of care. Other departments such as case management and hospitalist service have utilized this model to improve transitions of care.


Melissa Mordecai is an acute care nurse practitioner at Kennedy University Hospital in Stratford, N.J. She has completed a disclosure statement and reports no relationships related to this article. Helene Burns is the chief nursing executive at the same hospital.



1. Lang PO, et al. Early markers of prolonged hospital stays in older people: a prospective, multicenter study of 908 inpatients in French acute hospitals. J Am Geriatr Soc. 2006;54(7):1031-1039.

2. Howie J, Erickson M. Acute care nurse practitioners: creating and implementing a model of care for an inpatient general medical service. Am J Crit Care. 2002;11(5):448-458.

3. Kleinpell RM. Acute care nurse practitioner practice: results of a 5-year longitudinal study. Am J Crit Care. 2005;14(3):211-221.

4. Naylor MD, et al. High-value transitional care: translation of research into practice. J Eval Clin Pract.  2013;19(5):727-733.

5. Boltz M, et al. Transitional Care In: Evidence-Based Geriatric Nursing Protocols For Best Practice. New York, N.Y.: Springer Publishing Company; 2012: 686.

6. Sole ML, et al. Comprehensive trauma patient care by nonphysician providers. AACN Clin Issues. 2001;12(3):438-446.

7. Hospital Consumer Assessment of Healthcare Providers and Systems.



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