Transitional Care | GT Independence

Elderly woman in wheelchair with nurse at home If you’re in and out of the hospital on a regular basis, you know about transitional care. But do you know how to make the process a more positive experience with a decreased likelihood of rehospitalization? The Transitional Care Model can help.

Transitional care refers to the coordination and continuity of health care during a movement from one healthcare setting to another or to home. This care is traditionally provided as needs change over the course of a chronic or acute illness.

The American Geriatric Society¹ completed an extensive study on the re-hospitalization rates of those who receive transitional care. Those who went through a transition in care types were 40% more likely to experience a preventable hospitalization and 58% more likely to experience any type of hospitalization than those who remained under care in their home.

Older adults and disabled individuals with multiple chronic conditions are particularly vulnerable to breakdowns in care during the transition process. The following things are the main contributors to gaps in care:

Poor communication
Incomplete transfer of information
Inadequate education of caregiver
Inadequate education of patient
Limited access to essential services
Absence of single point person in charge of continuity of care
Existing standards which focus only on outcomes within settings

According to the Journal of the American Geriatrics Society², interventions such as discharge planning process, coaching patients, and home visits by an advance practice nurse can reduce re-hospitalization. Of those studied, 22% of individuals who had a physician follow-up visit were readmitted, compared to 52% of those without a follow-up visit.

In order to combat these common contributors, the Transitional Care Model has been created to address the negative effects and prepare patients and caregivers to manage changes in health. This model can help to decrease the likelihood of re-hospitalization along with improving health outcomes after hospital discharge and increasing your satisfaction with the care process. The Transitional Care Model includes ten essential elements for smooth transitional care.

Use of advanced knowledge and skills by a transitional care nurse to deliver and coordinate care of high risk patients within and across all healthcare settings. The transitional care nurse is the primary coordinator of care throughout the care transition process and ensures continuity.
A comprehensive assessment of the patient’s priority needs, goals, and preferences.
Collaboration with the patient, caregivers, and team members in implementation of a streamlined plan of care to promote health and cost outcomes.
Regular home visits by the transitional care nurse with ongoing telephone support.
Continuity of healthcare between hospital, post-acute and primary care healthcare professionals facilitated by the transitional care nurse to prevent or follow-up on acute illness care.
Active engagement of patient and caregivers, with a focus on meeting their goals.
Emphasis on patient’s early identification and response to health care concerns.
Multidisciplinary approach that includes the patient, caregivers, and healthcare professionals as team members.
Strong collaboration and communication between the patient, caregivers, and health care team across episodes of acute care and in planning for future transitions.
Ongoing monitoring to improve transitional care.

If you have a regular caregiver and healthcare professionals, discuss this model as your preferred method of transitional care before it is needed. Alternatively, ask your healthcare professionals what their model of transitional care looks like and compare it to this model. It can also be helpful to have a family member involved in the process to keep notes and ensure all members of your care team are on the same page when it comes to your transitional care.

For those transitioning to home and community based care, the Journal of the American Geriatrics Society¹ explains that it is especially important to maintain a consistent set of providers who are familiar with medical needs and have high accessibility. These individuals should be focused on ways to improve the transition and ease into the changes that come along with transition.

According to the American Geriatric Society¹, transition programs should not end at the time of transition. Counseling or case management throughout the process and frequent follow-ups could help to address problems or unmet needs before they lead to more intensive care needs or to decline.

No matter what transitional care model is used, be sure to stay involved in the care process and educated about your care.

¹Wysocki, A., Kane, R.L., Dowd, B., Golberstein, E., Lum, T., & Shippee, T. (2014). Hospitalization of elderly medicaid long-term care users who transition from nursing homes. Journal of the American Geriatrics Society, 62(1), 71-78.

²Yin, C. Y., Barnato, A. E., & Degenholtz, H. B. (2011). Physician follow-up visits after acute care hospitalization for elderly medicare beneficiaries discharged to noninstitutional settings. Journal of the American Geriatrics Society, 59(10), 1947-1954.