The frequent and cyclical nature of transitions to and between the hospital and other settings of care among the chronically ill older adult patient population make continuity and consistency of care a necessary ingredient to improving outcomes. As evidenced by this model and Penn team’s research findings, contact with a single provider who coordinates every aspect of care is an essential component of success.
Under this model, patients and their problems are viewed holistically. To care for each patient—at the point in his/her health trajectory where s/he is—each Transitional Care Nurse must focus on all health concerns, not just those that resulted in the initial hospitalization. Actively engaging each patient and his/her family/caregivers in management, education, and support are important components to this model.
While the acute care episode and the initial transition to a subsequent setting of care are immediate challenges, TCM emphasizes positioning each patient and his/her family/caregivers for longer-term positive outcomes. Through comprehensive assessment, early identification and diagnosis, and rapid response to health care risks and symptoms, a better trajectory is secured for every patient.
A key lesson from the provision of this model to more than 1,500 patients is the importance of a multidisciplinary approach. Transitional Care Nurses coordinate and collaborate care among and between different settings of care and different professionals including, but not limited to, physicians, care managers, discharge planners, pharmacists, therapists, social workers, and spiritual counselors. Strong collaboration with all providers contributes to a streamlined and rational plan of care for the patients.
The quality and amount of information derived from being in patients’ homes and seeing them function in their own environment cannot be under emphasized. Through home visits, the nurse can really see how patients are managing their medications, their home environment, and the interaction between their environment and their health (e.g., the presence of mold in the apartment of a COPD patient; plants that could cause allergies; stressful living conditions). These frequent and repeated opportunities to gather patient and family caregiver information, conduct ongoing assessments, provide teaching and patient/family education, and to reinforce healthy behaviors are hallmarks to this model.
Tailored, ongoing communication makes a significant difference in patient care. During the inpatient stay, the amount of information that needs to be conveyed is extensive, but because hospitalization is a stressful and vulnerable time for most patients, the extent information is absorbed and translated into self-care is diminished. In the first visit, the Transitional Care Nurse spends a fair amount of time reviewing the discharge instructions and medication instructions to ensure that the patient really understands them. There is a significant need for “translating” information between physicians and patients to ensure that each really understands what the other has communicated. Excellent communication between and among the patient, family/caregivers, and providers and the transfer of data, aided by clinical information systems, proves paramount.
Medication Management Essential to Successful Transitions. Among the chronically ill older adult population, whose medications often exceed eight, close management is essential to safety and effectiveness. The Transitional Care Nurse helps the patient develop a comprehensive system for managing medication that is customized to each patient’s individual needs and situation.
For many patients who lack significant social support systems in the home or available nearby (e.g., housing, psychological counseling, community activities), the Transitional Care Nurses are both their advocates and means to obtaining services that enable self-management and improved outcomes.