Making a Difference
Thomas Lowe is a 78 year-old African American man with a primary diagnosis of heart failure. He has six other chronic conditions for which he is receiving medications including hypertension, diabetes and coronary artery disease. Mr. Lowe was admitted to the acute care hospital through the emergency department when he arrived for a routine ophthalmology appointment acutely short of breath from walking three city blocks at a moderate pace.
Following the acute care hospitalization, Mr. Lowe returns home without any services, as he was not eligible for Medicare skilled home health care. Discharge instructions did not reflect Mr. Lowe's individual behaviors, needs, literacy level, or learning style. Mechanisms to reinforce and validate learning were absent and Mrs. Lowe was not involved in any of the teaching, identification of needs, or development of his plan of care. Her physical health suffers as a result of caring for her husband and grandchildren. For Mr. Lowe, who distrusts the health care system, this experience reinforced his suspicions and concerns and resulted in low satisfaction with care.
While this scenario repeats itself regularly in communities across the United States, an evidence-based alternative model of care is available: the Transitional Care Model (TCM). Tested and refined over twenty years by a multidisciplinary team at the University of Pennsylvania, TCM has improved health outcomes, prevented avoidable rehospitalizations, enhanced patient and family caregiver satisfaction and decreased health care costs.
The Transitional Care Model serves as an alternative and complement to traditional care coordination, case management under Medicare, and home- and community-based wavier services under Medicaid. Because the Model has consistently demonstrated improvements in patient outcomes and reductions in health care costs, public and private payers, employers, and policymakers should be aware of and advocate for national access to and implementation of this Model.