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Transitional care refers to the process of moving a patient from one healthcare setting to another, such as from a hospital to a nursing home or from a hospital back to the patient’s home. Organizations like TCPAMD aim to assist SNFs and long-term care facilities to ensure a smooth and safe transition of patients from hospitals to long-term care facilities to prevent any adverse health events that may occur during the transition of care.

Established in 2014 under the leadership of Dr. Amar Mohan, the Transitional Care Physicians of America (TCPA) seeks to revolutionize the way transitional care is delivered. The organization has paved the way for a new care delivery model that improves care for those who were previously insufficiently accounted for by the healthcare system. The organization partners with leading hospitals, rehabilitation centers, and assisted living communities to enhance healthcare transitions.

The Transitional Care Physicians of America website, TCPAMD, serves as a resource for its clients, offering a variety of tools and information to support them in their work. The website includes educational resources, news and updates, and information about the organization’s initiatives and programs. 

How Transitional Care Physicians of America Makes Transitions Easier

Transitional care is particularly important for older adults and patients with chronic illnesses, as they are at higher risk of complications and adverse events during transitions. These patients often require coordinated and continuous care across multiple healthcare settings to manage their complex medical conditions and prevent hospital readmissions.

The Transitional Care Physicians of America (TCPAMD) partners with long-term care facilities to help them facilitate better transitional care. Without the help of the TCPAMD, Skilled Nursing Facilities (SNFs) would face greater barriers to transitional care, such as:

1. Communication breakdown

A frustrated nurse experiencing communication breakdown during transitional care in a facility that does not have the assistance of TCPAMD.
When communication breaks down, patients are at risk of receiving duplicative or conflicting treatments, leading to potential harm.

Care transitions from hospitals to long-term care facilities can be complex, which is why the exchange of information between healthcare providers is an important part of ensuring that patients receive the right care at the right time. When communication breaks down, patients are at risk of receiving duplicative or conflicting treatments, leading to potential harm.

One reason for communication breakdowns is a lack of standardization in the exchange of patient information between healthcare providers. In many cases, healthcare providers use multiple electronic health record (EHR) systems that are incompatible, making it difficult to access and share patient information. This can lead to confusion and mistakes, especially when a patient is moved from one healthcare setting to another. This is why a facility must choose senior care software with excellent data interoperability capabilities.

Communication breakdowns can also be caused by a lack of care coordination between healthcare providers. When providers are not communicating effectively, important information about a patient’s health status and care plan is easily overlooked. This results in missed opportunities to identify and respond to health risks, leading to adverse events and hospital readmissions.

2. Inadequate patient education

Patients who are not adequately informed about their health conditions and treatments are more likely to struggle with: 

  • Inconsistent medical recommendations 
  • Complex medication schedules 
  • Vague directives for follow-up care 
  • Exclusion from transition planning 
  • A lack of comprehension of one’s health status and treatment plan

One of the reasons for inadequate patient education is the lack of time available during transitions between healthcare settings. When patients are moved quickly from one healthcare setting to another, there may not be enough time for healthcare providers to fully educate them about their health conditions, medications, and treatment plans. 

This is because nurses and physicians are more concerned with not making safety lapses during care transitions. As a result, patients feel overwhelmed and confused about managing their health, leading to incorrect medication management and adverse patient effects.

Another reason for inadequate patient education may be the lack of emphasis on patient-centered care in a long-term care facility. When nurses are focused on the technical aspects of care, they may overlook the importance of educating patients about their health conditions and treatment plans. This can result in patients feeling uninformed about and disengaged from their care, leading to sub-optimal health outcomes.

3. Lack of accountability

When there is no clear sense of responsibility for a patient’s care during their transition from a hospital to a nursing home, there can be gaps in the continuity of care and a lack of follow-up on critical health issues. This can result in adverse events, hospital readmissions, and increased healthcare costs.

One reason for this lack of accountability is the fragmented nature of the healthcare system. When patients move from one healthcare setting to another, those who treat them are not always familiar with their health history and treatment plans. Further complicating matters, some new nurses and physicians may not be utilizing a long-term care EHR with effective data transfer capabilities. This can result in duplicative or conflicting treatments and a lack of follow-up on essential health issues, putting the resident’s health at risk.

A lack of accountability can also be the result of unclear processes and protocols when coordinating care during transitions. When acute care and post-acute care facilities do not have clear guidelines for exchanging information and coordinating care, there can be misunderstandings and missed opportunities to address important health issues. 

To improve care delivery and outcomes during these transitions, nursing homes, assisted living, and other long-term care facilities must have a structured and collaborative approach. This is why the work of TCPAMD is so valued, as this organization provides a unique care model that combines highly trained clinical staff with evidence-based protocols and a patient-centered approach. 

The TCPAMD care model addresses a wide range of strategic goals, from minimizing hospital readmissions to avoiding adverse events, and it includes the following key elements:

Nurses in a meeting with professionals from the transitional care physicians of America
TCPAMD’s care model addresses a wide range of strategic goals, from minimizing hospital readmissions to avoiding adverse events.
  • In-facility care delivery guided by an evidence-based plan of care: TCPAMD’s evidence-based plan of care ensures that patients receive the right care at the right time.
  • Active engagement of patients and their families and informal caregivers: This involves TCPAMD’s team providing patients and their families with the education and support they need to navigate the transition process.
  • A multidisciplinary approach rooted in the Accountable Care Unit: This TCPAMD approach to transitional care includes the patient, family, and staff as part of the care team. Doing so ensures all stakeholders are involved in the care process and working towards the same goals.
  • Care coordination with members of the care team: By working closely with other members of the long-term care facility’s care team—including primary care providers and specialists—TCPAMD coordinates care while ensuring a seamless transition for patients.

By combining evidence-based protocols and a patient-centered approach, TCPAMD helps long-term care facilities improve care delivery, minimize hospital readmissions of residents, avoid adverse health events, and enhance the overall resident’s transition experience.

Contact us here if you would like to improve your care coordination with an effective long-term care EHR.

The Transitional Care RN: A Guide To Successful Patient Transition 

A transitional care RN is crucial in ensuring safe, timely, and efficient patient transitions. By working together with a TCPAMD team, long-term care nurses can promote successful transitional care of patients and residents by developing a transition care plan while identifying and communicating any potential problems that arise with the plan.

The role of nurses in transitional care typically includes:

A transitional care RN with a newly admitted nursing homer resident.
By fully understanding their roles, nurses can better contribute to improving the quality of care, elevating health, and reducing costs during transitional care.
  • Facilitating the safe, timely, and efficient transfer of information between care settings
  • Standardizing handovers and establishing procedures for communication and accountability with the help of the Transitional Care Physicians of America (if the facility chooses to work with them)
  • Training patients and families on using technology, such as family portals to access clinical information
  • Assessing caregiver capacity to provide appropriate care and their readiness to assume the caregiving role
  • Supporting stroke survivors and their families through care transitions by providing training and resources
  • Combining skill-building interventions like TCPA training for facility staff with psychoeducational strategies for optimal outcomes, especially when caring for stroke survivors and caregivers
  • Managing medication administration
  • Coordinating an effective discharge plan to ensure all patients and caregivers are prepared for active involvement in their aftercare treatment

By fully understanding their roles in the context of the TCPAMD model, nurses can better contribute to improving the quality of care, elevating health, and reducing costs during transitional care.

TCPAMD and the Future of Transitional Care

TCPAMD is a pioneer in the realm of transitional care services, offering a unique approach to care delivery that prioritizes evidence-based practices, integrated care delivery, and patient-centered care. 

In addition to providing their services to long-term care facilities such as nursing homes, assisted living, and skilled nursing facilities, the team at TCPAMD also supports transitional care for home-bound patients on-site and through telemedicine solutions. It is for these reasons that long-term care facilities turn to TCPAMD for transitional care services with the goal of delivering the best possible care to their transfer patients. 

For more on recent trends in long-term care, read our blog and subscribe to the LTC Heroes podcast.

Elijah Oling Wanga