Who Benefits
"It's really about helping and facilitating patients and their families...to understand how they can take care of themselves and manage the disease. Not have the disease manage them."
Marilyn P. Chow, RN, Vice President, Patient Care Services, Kaiser Permanente, Oakland, CA
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.
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.
Every patient participating in TCM receives individualized care based on a tested protocol. Patients and their informal caregivers, including family members and the extended support system, are TCM's central focus. The model is entirely patient- and family-focused and creates and sustains an enduring, continuous, trusting, and healing relationship among and between patients, family caregivers and the Transitional Care Nurses. This is accomplished through the identification of patients' and caregivers' goals, development and implementation of individualized plans of care, application of effective communication, and the adoption of evidence-based care.
While the elements of the protocol are standard, the Transitional Care Nurse (TCN) tailors specific interactions and interventions with each patient based on his/her unique circumstances.