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Transitional care and the older adult with chronic congestive heart failure : the major challenges and barriers for nurses and interdisciplinary health care professionals accross the continuum of care Brown, Susan Patricia

Abstract

Both the lack of knowledge and lack of integration of interdisciplinary approaches to discharge planning during the transitional care period for the older adult with CHF were resulting in poor client outcomes. The aim of this study was to identify the support required by nurses and interdisciplinary health care professionals in acute and community care settings to improve transitional care and discharge planning for the chronically ill older adult with CHF. Five focus group sessions were conducted using the Participatory Action Research Method. Focus group interviewing was used to prompt the views and perspectives of seven health care professionals regarding the major challenges and barriers during discharge planning and transitional care. Content analysis using processes found in grounded theory and process analysis found in focus group research were used to analyze the data. This study revealed the need for alternative strategies to improve care delivery during the transitional care period. The Chronic Care Model was recommended as the model of care for the chronically ill older adult with CHF in conjunction with a transitional care model that is client focused, integrated, interdisciplinary, and flexible to client's individual circumstance.

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