Issue link: https://digital.copcomm.com/i/1342648
Working Nurse l WorkingNurse.com 13 February 22-March 29, 2021 likely to have complications or ICU admissions. The program was expanded to all nursing units, and we just completed an implementation study in three partnering Magnet hospitals. As often happens in research, this project suggested other areas to investigate. Our successful inpatient effort led us to look at what happened to frail older adults after discharge. We ran a demonstration project, an adaptation of the Transitional Care Model developed by Mary Naylor, RN, Ph.D., FAAN, in which we sent advance practice nurses to patients' homes to manage care and health interventions. This program was subsequently adopted by our Medical Delivery Network and has been successful in reducing hospital readmissions. An "Epic" Study During the demonstration project, we noticed that several patients shared the same address, a building in an apartment complex for independent, low-income older adults. The tenants in this complex told us their greatest health concern was the risk of losing their independ- ence and ending up in permanent long-term care. We set to work collaborating with tenants and housing management to create a program to help prevent ill- ness and injury and thus reduce tenants' need for high- cost acute and long-term care. This was the genesis of the study we are preparing to launch, which is entitled EPIC, for Elders Preserving Independence in the Community. We have funding from the Patient Centered Outcome Research Institute (PCORI) to study the comparative effectiveness of two evidence-based interventions: onsite health promotion/illness preven- tion classes and in-home preventive health care visits by an advanced practice nurse. Our whole research team is involved in this project, which could ultimately benefit many older adults. Currently, we are working with the housing providers on how best to conduct our study with appropriate COVID-19 precautions. The study kicks off this month. We're looking forward to seeing where it leads us next. WN INTERPROFESSIONAL TEAMWORK Above, in white coats: The team's director, Bernice Coleman, RN, Ph.D. (foreground), a nurse practitioner in cardiac transplant, with team leader Harriet Aranow, Ph.D. (back- ground). Smaller photos, clockwise from top left: Selena Davis, Lucia Florindez, Margo Minissian, Linda Kim, Xu-Wenrui, Mana Manoukian, Nia Mabrie, LaKeisha Hall. We were all drawn to this team by the intense desire to make a difference in real-world healthcare delivery.