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During exacerbations of Congestive Heart Failure CHF older patients may receive care in multiple settings often resulting in fragmented care and poorly-executed care transitions The negative consequences of fragmented care lead to duplication of services inappropriate or conflicting care instructions medication errors patientcaregiver anxiety and increased costs of care In light of changes in Medicare reimbursement penalizing hospitals with above set limits for heart failure HF readmissions models of care are being evaluated for their effectiveness in satisfying this change as well as reducing fragmented care in this population This paper reviews the Transitional Care Model created by Dr Mary Naylor at the University of Pennsylvania Penn Nursing Science 2013 This model in introduces a patient-centered interdisciplinary team intervention designed to improve transitions across care settings Congestive Heart FailureCongestive heart failure CHF is a condition in which the heart is incapable of adequately pumping blood throughout the body or unable to stop blood from backing up into the lungs The most common cause of CHF is hypertension previous myocardial infarctions disorders of the heart muscle or the valves of the heart and chronic lung diseases such as asthma or emphysema CHF is a common diagnosis for individuals sixty five years and older With the growing population of baby boomers the rate of CHF is predicted to nearly double over the next forty years and will be a drain on healthcare resources Treatment costs are estimated around 20 to 40 billon with 8 to 15 billion spent on hospitalization alone Quaglietti Edwin Ackerman Froeliher 2000One in four patients hospitalized for CHF are re-hospitalized within thirty days of discharge This high rate of readmission has brought negative attention from
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