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Transitional care models are used to assist chronically ill patients and seniors transitioning between healthcare providers and settings, such as hospitals, skilled nursing homes, assisted living facilities, nursing homes, primary care physicians, home health, and specialists. 

One of the main goals of transitional care models is to develop a comprehensive patient care plan that addresses a patient’s personalized needs while providing a continuum of care across multiple care settings. That usually means incorporating logistical arrangements, patient and family education, and the coordination of services during care transitions. The process can be summarized in these steps: 

Assessment: The process of transitional care models usually starts with a transitional care nurse who specializes in caring for patients with chronic health conditions, such as heart disease, stroke, chronic obstructive pulmonary disease, cancer, and diabetes. 

Admissions: The nurse will conduct a thorough patient assessment, gathering data on a patient’s health status and behaviors, level of care and social support needed, and health goals. 

Accumulating Data: Information will be entered into the healthcare provider’s eMAR software system so that the transitional care nurse can develop a personalized care plan for the patient. 

Access: Once a care plan is created, it can be accessed by authorized personnel, such as physicians, nurses, and social workers, who will follow the evidence-based nursing documentation to provide daily care and ensure the patient is in optimum health when discharged. 

Appointments: The transitional care nurse will continue care even after discharge by conducting home visits or remote appointments for approximately 12 sessions, ensuring a smooth transition between the hospital and the home setting. 

Adjustments: The nurse will also be available on-call via telephone so patients or their families can access additional medical advice when needed. This is crucial, as it allows the nurse to identify changes in the patient’s health condition while managing and making adjustments to patient care when needed.  

The 5 Transition of Care Models

As mentioned earlier, transitional care refers to moving patients between healthcare settings and providers, such as from a hospital to a skilled nursing facility or a patient’s home. However, there are several transition of care models, each with varying components but with the same purpose in mind: bridging the care between healthcare settings so that patients can receive appropriate and coordinated care during the transition process. 

Here we will discuss the different transitional care models, highlighting the components and similarities between the models. 

After studying several transitional care models, a physician and a nurse are assisting a senior who is transferring between healthcare settings.
Transitional care models assist chronically ill patients and seniors transitioning between healthcare settings.
  1. Transitional Care Model (TCM)

The Transitional Care Model (TCM) revolves around a nurse-led interdisciplinary team that improves patient outcomes while reducing hospital readmissions. The critical component of TCM is to assist patients when transitioning across healthcare settings by identifying patient goals and developing an individualized care plan. TCM usually starts in the acute care setting, with care continuing to the community or home care settings.

  1. Care Transitions Intervention (CTI)

Care Transitions Intervention (CTI) is an evidence-based model that improves patient engagement and healthcare management. It is a short-term model, usually lasting for 30 days, where patients with chronic illnesses or complex care issues work alongside a transition coach to build or improve self-management skills. This allows them to transition from the hospital to their homes more easily. 

There are four components of CTI, the four pillars of health, and they are used to measure a patient’s condition:

A nurse is adhering to transition of care models to provide coordinated care to a resident.
Transition of care models bridge the care between healthcare settings so patients can receive coordinated care.
  • Patient-centered record: The patient and their family are given access to their Personal Health Records (PHR), which are used to communicate effectively with caregivers while ensuring proper continuity of care across all healthcare providers and settings. 
  • Medication self-management: The interdisciplinary team will educate the patient and their families about the prescribed medication and how to manage the dosage appropriately.
  • Primary care and specialist follow-up: Patients and their families are encouraged to participate in these sessions during primary care or specialist appointments.
  • Red flag awareness: The patient and their family are given educational information about their health conditions, so if their condition deteriorates, they can recognize the symptoms and act accordingly.
  1. Better Outcomes for Older Adults Through Safe Transitions (BOOST)

BOOST is a transitional care model that helps older adults understand and follow their medical treatment and care instructions more carefully after they are discharged from a hospital. The model uses standardized tools to educate seniors about their discharge needs, tests their understanding, and improves medication administration when discharged. 

This model ensures the patients fully comprehend their diagnoses, treatment plans, and follow-up care, improving patient outcomes. Furthermore, it reduces hospital readmissions, as seniors gain a better understanding of self-care and healthier lifestyles to pursue upon returning home. 

  1. Project Re-engineered Discharge (RED)

The RED transitional care model improves the process of patients leaving the hospital by making it more efficient, safer, and more accessible for them to understand their medical conditions and treatments. The program educates patients about healthier lifestyle practices after they leave the hospital. 

RED also reduces common discharge errors, like medication misunderstandings, dosage errors, or how frequently medication should be taken, ensuring patients are given the correct information and resources to care for themselves at home. These factors provide a smoother transition from the hospital to home, giving patients the necessary information.

  1. Chronic Care Model (CCM)

The Chronic Care Model is used to aid chronic conditions like diabetes, heart disease, or cancer. It focuses on an interdisciplinary team working together to help patients manage their health needs. 

The primary purpose of the CCM is to improve patients’ overall health and well-being by giving them the proper care, tools, and support to successfully manage their long-term health conditions while reducing hospital readmissions. 

Even though there are several transitional care models, they all have one purpose: to provide patients with the necessary information and resources they need to understand their health conditions and how to care for themselves better. The next section will examine how transitional care can improve patient care. 

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How Transitional Care Enhances Patient Care and Patient Outcomes

As mentioned above, transitional care aims to improve patient care and outcomes by ensuring a smoother transition from the hospital to home or another healthcare setting. 

Using any of the transitional care models listed above can enhance transitional care due to the detailed patient assessments of the patient’s needs, their family and caregivers, and the community providers or settings. All of these contribute towards administering proper medication and safe continuity of care to reduce the likelihood of hospital readmission with a customized discharge plan. 

It is also important to help case managers better understand and adopt different best practices to support successful care transitions that improve patient outcomes. In fact, studies show that hospital case managers play a crucial role in care transitions by assessing patients’ risks and goals while coordinating care and services among healthcare providers and settings. They are also tasked with coordinating medication prescriptions and educating patients to improve self-management and self-care.

Similarly, nurses can better perform their jobs by referring to the best transitional care models for nurses, such as Penn University’s TCM, which highlights the problems associated with unplanned readmissions for older patients with complex chronic conditions. These transition of care models are used to help seniors when being discharged from hospitals, giving them appropriate follow-up care. The Transitional Care Model (TCM) services include:

A nurse is assisting a resident by following transitional care methods to ensure a smoother transition between healthcare settings.
Transitional care improves patient care and outcomes by ensuring a smoother transition between healthcare settings.
  • Daily assessments of high-risk elderly patients in the hospital
  • Creating an appropriate care plan that coordinates proper inpatient care 
  • Detailed assessments of the patient’s health goals and needs
  • Designing an evidence-based transitional care plan for the patient after they leave the hospital
  • Providing educational materials for patients and their caregivers to support symptom management 
  • Sharing relevant resources on how patients and their caregivers can access community and social services when necessary
  • Scheduling regular home visits and telephone calls after discharge
  • Encouraging patients with multiple care providers to obtain the appropriate care services and medical equipment
  • Continued reassessment of the patient’s status, their caregivers, and primary care providers
  • Accessibility by telephone seven days a week

This nurse-led program has proven successful because it has expanded to include primary care patients within selected regional medical home programs. Furthermore, those using the program have also seen enhanced patient satisfaction and improved patient outcomes.

The Importance of Transitional Care Models

Transitional care models offer a vital service for patients discharged from the hospital. They ensure patients receive the recommended follow-up care while guiding them to the information they need for a full recovery, thus putting their minds at ease about their health conditions. Such collaborative care plans, home visits, and telephone support services ensure patients can monitor and manage their care transitions more successfully, leading to better health outcomes and fewer hospital readmissions. 

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