Transitional Care

In 2005, INQRI launched with an initial focus on patients in acute care settings. However, to ensure that the program would produce results that could be used to widely benefit health care consumers, the focus was expanded. In its third funding cycle, INQRI began accepting proposals that would focus on nursing care across settings. This shift allowed the program to also include transitional care projects.  Transitional care refers to a range of services that complement primary care and are designed to ensure continuity of the quality of care provided across settings by multiple providers.

INQRI grantees have contributed much to this field of research. Led by Barbara Roberge and Ken Minaker, a team at Massachusetts General Hospital tested the impact of identifying and communicating a pre-hospital preventive patient risk profile on nurse-sensitive outcomes for hospitalized older adults. Researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva, studied what hospital-based nurses do to influence outcomes after a patient is discharged from a hospital. They identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. Cynthia Corbett, Stephen Setter and their team at Washington State University used information technology to help home care nurses more efficiently and effectively identify and resolve medication discrepancies as patients transitioned from the hospital to home. Researchers at the University Pennsylvania, led by Nancy Hanrahan and Phyllis Solomon, are working on a translation of the Transitional Care Model for use with people with serious mental illness as they transition in an out of psychiatric hospitals and emergency services.

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