Who Benefits?
TCM has been designed for older adults with two or more risk factors, including history of recent hospitalizations, multiple chronic conditions or medications, and poor ratings of self-health. In addition, TCM is currently being tested among hospitalized older adults with dementia and long-term care recipients being transferred to and from acute care hospitals. Access to TCM is expanding and may be available to you or your loved one.
"It provides (me with) information on how to deal with the health care system; someone to...speak for you. When you are sick you don't have the energy to advocate for yourself."
Patient, Richmond, VA
Effect on Quality, Cost, and Value
TCM was developed to (1) address the negative effects associated with common breakdowns in care when older adults with complex needs transition from an acute care setting to the home or other care settings and (2) prepare patients and family caregivers to more effectively manage changes in health associated with multiple chronic illness. Across three rigorous scientific studies, TMC has achieved positive results:
Avoidance of hospital readmissions for primary and complicating conditions. TCM has resulted in fewer hospital readmissions for patients. Additionally, among those patients who are rehospitalized, the time between their discharge and readmission is longer and the number of days spent in the hospital is generally shorter than expected.
Improvements in health outcomes after discharge. Patients who received TCM have reported improvements in physical health, functional status and quality of life.
Enhancement in patient and family caregiver satisfaction. Overall patient satisfaction has increased among patients receiving TCM. In ongoing studies, TCM also aims to lesson burden among family members by reducing the demands of caregiving and improving family functioning.