A nurse-led hospital discharge and home follow-up program for chronically ill older adults.
The Transitional Care Model is designed to prevent health complications and rehospitalizations of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up, coordinated by a master’s-level “Transitional Care Nurse” who is trained in the care of people with chronic conditions. At the time of hospitalization, the Nurse: (i) conducts a comprehensive assessment of the patient’s health status, health behaviors, level of social support, and goals; (ii) develops an individualized plan of care consistent with evidence-based guidelines, in collaboration with the patient and her doctors; and (iii) conducts daily patient visits, focused on optimizing patient health at discharge.
Following discharge, the Nurse conducts periodic home visits and/or scheduled phone contacts with the patient based on a standard protocol. In Study 1 (below), the post-discharge program lasted three months, and included an average of 12 home visits, with no scheduled phone contacts. In Study 2 (below), it lasted approximately one month, and included an average of 4.5 home visits and weekly Nurse-initiated phone contacts with patients or family caregivers. In both cases, the Nurse was also available to patients via telephone seven days per week.
Two main focuses of the Nurse home visits and phone contacts are: (i) identifying changes in the patient’s health and (ii) managing and/or preventing health problems, including making any adjustments in therapy in collaboration with the patient’s physicians. The Nurse also accompanies the patient to her first physician visit following hospital discharge to ensure effective communication.
Each Nurse handles a caseload of 18-20 patients. The Transitional Care Model replaces the hospital’s usual discharge-planning and post-discharge activities. Its cost ranges from $519 per patient (in Study 2) to $1,160 per patient (in Study 1), in 2017 dollars.