Relational processes in heart failure care transitions: A data-driven case report.

Effective patient care transitions require consideration of social and clinical context, yet how these factors and relational processes in care coordination relate remains poorly described. This case report aims to describe provider networks and the clinical care and social context involved during longitudinal care transitions across settings.We examined the utilization and provider networks of an oldest old woman with heart failure (HF) before and after her first hospitalization for HF. She used primary care for care management and had insurance, strong caregiver support, and comprehensive discharge planning; however, after the hospitalization, Mrs. A's ambulatory provider networks were more diverse yet sparser and less strongly connected.Turbulence in care transition can result from sources other than transitioning between settings. The data-driven case report approach using electronic health records uncovered relational processes important for care coordination and may inform patient-centered approaches to improve care for patients with HF.

Duke Scholars

Author Wei Pan School of Nursing

Author Eleanor Schildwachter McConnell School of Nursing

Author Kirsten N Corazzini School of Nursing

Author James Moody Sociology

Author Bradi Bartrug Granger School of Nursing