The Nursing Ambulatory to Hospital Transitions Program (NAHT) aims to determine whether communication of a preventive nursing care plan between ambulatory and hospital nurses will impact nursing quality for hospitalized older adults. Communication of nursing knowledge between ambulatory and hospital nurses during home-to-hospital transitions will focus on risk recognition and may be key to prevention and thus central to patient outcomes. As part of this three phase Robert Wood Johnson Foundation funded study the researchers will (phase one) develop a pre-hospital nursing risk index by identifying office based predictors of hospitalization in vulnerable older adults and (phase two) describe the patient's hospital trajectory as a function of  how nurses manage the care of older adults.  Phase three is our randomized control trial (RTC) of the communication intervention. We are especially interested in frailly and vulnerability during transitions into and throughout hospitalization.  Specifically data will be collected about the nursing care requirements, the timing of interventions and how nurses manage these complex phenomena over the course of a hospitalization.
 
Our unique focus is on how nurses might change the patient's trajectory through communication and prevention. This study contributes to knowledge development in transitions research, which has historically emphasized transitions from hospital-to-home. We will focus on the transition from home-to-hospital, important because knowledge of patients’ risk profile before hospitalization has the potential to improve patient outcomes. This study will expand our knowledge of the nursing needs of vulnerable elders and begin to answer if improved communication has the ability to change patient outcomes in this vulnerable population. From a policy perspective the most vulnerable elders are also costly withhealth care cost for individuals with at least three chronic conditions accounting for most of Medicare’s annual budget. Developing risk indexes prior to hospitalization then following the hospital trajectories of older adults reveals important information about the actual utilization of health care resources and begins to answer fundamental question about nursing quality for hospitalized older adults.

 
Funding Agency:  Robert Wood Johnson Foundation: Interdisciplinary Nursing Quality Research Initiative (INQRI) Amount $300,000 over 2 years.
  
Barbara J. Roberge PhD, APRN, BC, PI, Dr. Sung Chuang MD, Dr. Kenneth Minaker MD, Ellen Mahoney RN, DNS, and Barbara Moscowitz LICSW, MSW.  

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