Professional Documents
Culture Documents
PROJECT GOAL
To improve clinical outcomes and quality of life for Californians with chronic disease.
OBJECTIVES
• Expand the number of providers who effectively care for patients with chronic conditions.
• Increase the participation of patients and families in all aspects of care.
• Offer strategies for handling challenges, improving communications, and
maximizing the benefits of family involvement in chronic illness care.
PROJECT OUTCOME
Twenty-five nurses in California will complete the Care Transitions online learning
module.
BACKGROUND
Rising rates of chronic disease require new modalities of health care delivery in
order to maximize quality of life and the health status of Californian’s. Chronic disease
affects an individual’s level of functioning and their ability to care for him/herself and is
associated with low quality of care. A client with a chronic disease such as hypertension
may need to seek care from several sources, such as a community clinic, private
physician’s office, or cardiologist (Anderson, 2007). One of the most vulnerable
transitions between care settings is after hospital discharge, when a client is discharged
home and they may feel under-prepared to manage on their own and lack an
understanding of their medication (Coleman, 2006). Nurses are in a unique position to
assist clients and their families with chronic disease management by developing clients’
ability for self-care, especially when transitioning between care settings.
*Note: Participants will be practicing nurses who spend 25% of the professional role in
direct patient care and no previous experience with formal Care Transitions programs.
M. KELLY QUALS GRANT PROPOSAL 3