Making a Difference
Fred Sallett is a sixty-eight year old man with a primary diagnosis of heart disease and eight other health problems that include high blood pressure, diabetes, and obesity. Mr. Sallett was admitted to the hospital for chest pain. Mrs. Sallett, his wife of 45 years, is his primary family caregiver.
Before Mr. Sallett is discharged from the hospital, the Transitional Care Nurse (TCN), a master's-prepared nurse with advanced knowledge and skills in the care of older adults, visits him, reviews written instructions for follow up care and explains her role. Over the course of the treatment plan, the TCN sees Mr. Sallett regularly for five weeks. Based on mutually agreed upon goals, Mr. and Mrs. Sallett and the TCN work to promote an effective transition from hospital to home and improve the management of Mr. Sallett's chronic diseases. For example, as part of that care, the TCN reviews all of Mr. Sallett's medications and provides a medication planner to make it easier for him to understand and follow his medication regimen. Furthermore, the TCN coordinates Mr. Sallett's care with his primary care physician and specialists. The nurse encourages Mr. Sallett to schedule all of his necessary follow up appointments and she communicates and collaborates with the cardiologist on Mr. Sallett's plan of care.
The TCN encourages and supports Mr. Sallett's interest in community activities, including attending a diabetic education course and a local senior center. The results of this individualized transitional care are improved heart health, high levels of patient and family caregiver satisfaction, and avoidance of another hospitalization.
Today's health care system is fragmented and routinely fails to live up to its potential. Recent reports have highlighted the significant gaps in quality and safety and the need for reform. While Mr. Sallett's story is not a common one in today's health care system, the customized and highly coordinated care provided by Mr. Sallett's Transitional Care Nurse is representative of an innovative model of care that has been tested and refined for over twenty years by a multidisciplinary team at the University of Pennsylvania. This model is known as the Transitional Care Model.
If you or an elderly family member has been recently hospitalized or suffers from multiple chronic conditions, the Transitional Care Model is an alternative approach to care that improves longer term outcomes and prevents hospital readmission.
Participating in TCM
Over 20 years of research and testing have contributed to this innovative model. Currently, TCM is available only in a few parts of the country. Efforts are currently under way to promote widespread use of this model. The Penn team is working to ensure that TCM is more widely available to those who will benefit from it the most.