Implementation Protocol
The Transitional Care Model targets cognitively intact older adults with two or more risk factors, including history of recent hospitalizations, multiple chronic conditions or medications, and poor self-health ratings. In addition, TCM is currently being tested among cognitively impaired hospitalized older adults 7 and long-term care recipients being transferred to and from acute care hospitals 8.
Every patient participating in TCM receives individualized care based on a tested protocol. While the elements of the protocol are standard, the TCN tailors specific interactions and interventions with each patient based on his/her unique circumstances. For example, the protocol dictates the minimum level of in-home telephonic communication between the patient and his/her TCN, but the actual number and length of telephone calls can exceed this protocol based on the patient's individual needs.
The standard protocol includes:
In-Hospital Visits with Patients.
In the acute inpatient setting within 24 hours of enrollment in the TCM program, the TCN conducts a comprehensive assessment of the patient's health status and defines priority needs and services for the patient and family caregiver(s) throughout the patient's stay. The TCN collaborates with the physicians and other members of the health care team to streamline the plan of care and to design and coordinate inpatient and follow-up care based on the comprehensive assessment and goals identified by the patient.
Home Visits with Patients.
The TCN visits each patient in his/her home within 24 to 48 hours of discharge from the hospital. After the initial visit, a minimum of one home visit per week during the first month is made, followed by semi-monthly visits until discharge from the program. The TCN makes telephone contact with the patient, as needed, and in each week an in-person visit is not scheduled. In addition, the nurses are available to the patients and their family/caregivers by telephone from 8am to 8pm Monday through Friday and 8am to noon on weekends, An explicit, personalized plan for emergency care during those hours when the TCN is unavailable. It is important to note that nurses rely on their clinical judgment and each patient's unique circumstances to determine the actual number and nature of contacts.
Nurse Visit with Physician.
The TCN accompanies the patient on his/her first visit with the physician post-discharge and on subsequent visits, if needed. During the initial visit, the TCN assures excellent communication related to the plan of care between hospital and primary care providers (PCPs). For example, prior to or during the visit the TCN provides a copy of the discharge instructions as well as the TCN's own summary on the status of the patient and plan of care. The TCN also helps the patient and his/her family caregivers to achieve their visit goals. For example, the TCN assists the patient and family caregiver to generate a list of questions prior to the physician visit so that the patient can get answers to major questions during the visit. The TCN directly facilitates and advocates for the patient with the physician. Immediately following the visit, the nurse also assists patients and family caregivers in understanding the PCP's instructions.
Transition from TCM.
At the end of the patient's participation in TCM, the TCN assures continuity of care and ongoing commitment to the patient's self-management goals through communication with the primary care provider who will continue to follow the patient. A transition summary prepared by the TCN is provided to patients and primary care providers. The patients' goals, progress in meeting these goals and on-going or unresolved issues with the plan of care are addressed in these summaries. In some cases, the TCN will also help facilitate access to palliative care or hospice services, assisted living, or chronic case management, based on the individualized needs of the patient and his/her family caregiver.
7 Naylor MD, Principal Investigator. Hospital to Home: Cognitively Impaired Elders and their Caregivers. National Institutes of Health, National Institute on Aging, Grant No.: R01AG023116, 2005-2010.
8 Naylor MD, Principal Investigator. Transitional Care of Hospitalized Nursing Home Residents. Rand-Hartford Center for Interdisciplinary Geriatric Health Care Research, University of Pennsylvania School of Nursing, 2005-08.