Transitional Care Nurses (TCN)
The heart of this model is the TCN, who follows participating patients from the hospital into their homes, and using an evidence-based care coordination approach, provides services designed to streamline plans of care and interrupt patterns of frequent acute hospital or emergency department use and health status decline. The TCN collaborates with patients' physicians in the implementation of tested protocols with a unique focus on increasing patients' and caregivers' ability to manage their care. In published studies of the model, the nurse who implements the intervention is an Advanced Practice Nurse who has a masters degree in nursing with advanced knowledge and skills in the care of older adults.
The TCN is an expert in providing comprehensive care to the chronically ill, versed in national standards of care delivery, and experienced in providing both acute and community-based services. The TCN provides direction to enhance the effectiveness of the health care delivery team. Both transitions across physical settings (e.g. acute to community), and transitions in health status are monitored and managed to improve patient care and outcomes. Each TCN manages an active caseload ranging from 15 to 20 patients, with an average of 18 patients. Current TCM demonstration projects are evaluating the use of bachelor's-prepared nurses and bachelor's-prepared nurses working in consultation with Advanced Practice Nurses.
"TCM really enables me to be part of the health care system. I'm able to work with a multidisciplinary team and make changes without being limited in scope. I am able to create 'teachable moments' for my patients who value the consistent, ongoing interaction. Many older people are lonely and having someone who is a constant in their lives helping them to navigate the system is invaluable. TCM has really enriched my knowledge base and how I want to work as a nurse."
Jill Murray, RN, MSN, CNS, Transitional Care Nurse, Kaiser Permanente - San Francisco Medical Center, San Francisco, CA
The TCN role is very different from a traditional nursing position. It incorporates the skills of a nurse, care manager, and patient advocate and knowledge of evidence-based care, managing complexity, palliative care, active engagement of family caregivers, interdisciplinary team care, theories and strategies for individualized care and behavioral change, quality improvement, and organization, delivery and financing of services across an episode of acute care.