Key Components

Key Components

TCM is built on the following key components:

Focus on Patient and Caregiver Understanding.

Patients often retain little of what they are taught while hospitalized. A great deal of information is communicated to patients and family members during hospital stays, but often the patient and caregivers are unable to absorb that information because being in the hospital is such a stressful and vulnerable experience. A key element of TCM is the priority on patient and family education both in the hospital and in the transition from hospital to home. For example, in the first post-discharge visit the TCN devotes significant time to reviewing the hospital discharge instructions to ensure that the patient really understands and can execute the plan of care. Emphasis is placed on "translating" information to ensure that each patient really translates what is being communicated.

Helping Patients Manage Health Issues and Prevent Decline.

Recognizing that home follow up under TCM extends one- to three-months, a significant part of the TCN's role is to facilitate each patient's and family caregiver's ability to manage his/her care at home. The TCN begins this process at the point of hospital admission, working with each patient and caregiver to identify their goals. Across the next one- to three-months, in the home, the TCN helps patients develop systems for managing their own care effectively and achieving their goals. The TCN works with the patient and family caregivers to develop an individualized, realistic plan of care that includes strategies to reach positive health outcomes aimed at preventing future acute care events. A major focal point of the nurse's efforts is to help patients and families develop the knowledge needed to identify and address health problems when they first occur. Each plan is customized and tailored to the individual patient and identifies the resources and level of change that patients and their family caregivers are willing to accept and execute.

Medication Reconciliation and Management.

During the patient's hospitalization, the TCN also reviews the medication plan with all providers, including the hospital pharmacist, to reduce the overall number of medications and eliminate contraindications and unsafe interactions. At hospital admission and the first post-discharge visit, the TCN performs medication reconciliation to assure the correct medications, in the correct doses, are documented in the patient's medical record and present in the home. Patient understanding of changes in medication dosing, brand versus generic names, and adherence with medications is a priority. The TCN instructs the patient about each medication stressing its rationale, schedule, side effects, dose in strength and number, and storage. The TCN assesses the patient's current system for managing medication and obtaining refills, and suggests changes to medication behavior as needed (e.g., obtaining pill planners, 90 day supply ordering). Each patient's ability to afford co-payments is assessed, issues surrounding prescription coverage and formulary restrictions are identified, and suggestions for changes to the medication plan, based on coverage, are discussed with the physicians.

Transitional Care, Not Ongoing Case Management.

The Model is designed to fill an important gap in health care delivery, helping patients make an important transition from the hospital to the home, minimizing declines in health status. The purpose of the evidence-based model is not to provide ongoing care to patients but to optimize patient outcomes throughout and following an acute episode of illness. The major goal of this model is to help the patient and family caregivers develop the knowledge, skills and resources essential to prevent future decline and rehospitalization. At the end of this episode of care, continuity is assured by excellent communication with the primary care providers continuing to follow patients who have made a commitment to their self-management goals. In some cases, the TCN will help facilitate access to palliative care or hospice services, assisted living, or chronic case management, based on the individualized needs of patients and their family caregivers. A transition summary prepared by the TCN is provided to patients and primary care providers who will assume responsibility for continuing care. The patient's goals, progress in meeting these goals and on-going or unresolved issues with the plan of care are addressed in these summaries.