Older adults with COVID-19 who survive hospitalizations and return to their homes confront substantial health challenges and an unpredictable future. Early evidence suggests that complex and long-term physical, functional, cognitive, and emotional negative health consequences will be the norm for them. However, the trajectories of health care needs of older adults with COVID-19 in the weeks and months following hospital discharge have yet to be identified.
In an article in the Journal of Aging and Social Policy, three researchers from the University of Pennsylvania School of Nursing (Penn Nursing) explain how the core components of the Transitional Care Model, along with early findings regarding the unique concerns of those with COVID-19, suggest a path for immediate practice and policy responses to caring for this population as they transition from the hospital back to the community.
The Transitional Care Model is a care management strategy proven in multiple National Institutes of Health clinical trials to enhance health and quality of life and reduce health-care costs for diverse subgroups of hospitalized older adults to home. It encompasses comprehensive discharge planning and home follow-up.
"Informed by this evidence-based framework, immediate implementation of targeted federal and state policy solutions would position health and community-based care systems to respond more effectively to the enormous challenges encountered by older adults with COVID-19 throughout transitions from hospital to home," wrote the three authors: Mary D. Naylor, PhD, RN, FAAN, the Marian S. Ware Professor in Gerontology and the Director of the NewCourtland Center for Transitions and Health; Karen B. Hirschman, PhD, MSW, research associate professor; and Kathleen McCauley, PhD, RN, FAAN, FAHA, Professor Emerita of Cardiovascular Nursing.
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