Transitional Care Model

By: Kim Maryniak, PhD, RNC-NIC, NEA-BC
Transitional Care Model

Healthcare is continually evolving, and there has been a movement towards providing care in the community rather than lengthy inpatient stays. However, there are vulnerable patients who are at risk for readmission to the hospital related to complications associated with disease processes and chronic illness. One strategy to help improve outcomes and reduce readmissions is the use of a Transitional Care Model (TCM). This model is led by nurses for those at risk patients to assist in transitioning patients across healthcare settings and between providers. Key components of this model include identification of patient goals, developing individualized care plans with the patient and team, and providing continuity of care throughout settings. TCM can begin in acute care settings, and care continued through to community and home settings (Hirschman et al., 2015; Laura and John Arnold Foundation, 2017; Nelson & Pulley, 2015).

Any transition, whether it is between healthcare settings or providers, can cause a gap in the care of a patient. Needed education and continuity of care may be lost during these periods of transition. There are various models of transitional care, but they have similar characteristics. Patients who need transitional care are those with cognitive or functional impairment, elderly patients, psychiatric co-morbidity, multiple co-morbidities, polypharmacy, two or more hospitalizations within six month, insufficient social support, poor health literacy, or difficulty with compliance (Hirschman et al., 2015; Nelson & Pulley, 2015). Additionally, international programs have included neonatal transitional care for families with infants discharging from intensive care (Alberta Health Services, 2019; British Association of Perinatal Medicine, 2017; Lasby, Newton, & von Platen, 2004).

Transitional care models involve interdisciplinary team members, and are nurse-led. The nurse may be an advanced practice registered nurse. Nurses follow up with patients through in-person visits and phone contacts. The nurses also hold discussions with other team members, such as the provider, ancillary therapy, and the family. Most nurses have a caseload of 18-20 patients, depending on the program structure. TCMs may be developed by acute care facilities, ambulatory employers, or a community collaborative. There is also an option to create stand-alone transitional care programs, with oversight of advanced practice nurses or physicians (Hirschman et al., 2015; Laura and John Arnold Foundation, 2017; Nelson & Pulley, 2015). Transitional care services are currently covered through Medicare and insurance companies, as provided by the Affordable Care Act (Centers for Medicare and Medicaid Services, n.d.; Nelson & Pulley, 2015).

Decreasing hospitalization length of stay has contributed to a cycle of readmissions for vulnerable patients. To offset the occurrence of readmissions and to improve patient outcomes, the Transitional Care Model, a nurse led care model, was developed.

Alberta Health Services. (2019). Neonatal transition team, postpartum community services. Retrieved from https://www.albertahealthservices.ca/findhealth/Service.aspx?id=1567&serviceAtFacilityID=1060417

British Association of Perinatal Medicine. (2017). A framework for neonatal transitional care. Retrieved from https://www.bapm.org/sites/default/files/files/TC%20Framework-20.10.17.pdf

Centers for Medicare and Medicaid Services. (n.d.). Transitional care management services. Retrieved from https://www.medicare.gov/coverage/transitional-care-management-services

Hirschman, K., Shaid, E., McCauley, K., Pauly, M., & Naylor, M. (2015). Continuity of care: The Transitional Care Model. The Online Journal of Issues in Nursing, 20(3). Retrieved from http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-20-2015/No3-Sept-2015/Continuity-of-Care-Transitional-Care-Model.html

Lasby, K., Newton, S., & von Platen, A. (2004). Neonatal transitional care. Canadian Nurse, 100(8), 18-23.

Laura and John Arnold Foundation. (2017). Evidence summary for the Transitional Care Model. Retrieved from https://evidencebasedprograms.org/document/the-transitional-care-model-evidence-summary/

Nelson, J. & Pulley, A. (2015). Transitional care can reduce hospital readmissions. American Nurse Today, 10(4), 1-8. Retrieved from https://www.americannursetoday.com/transitional-care-can-reduce-hospital-readmissions/  

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