Quality, Cost, and Value
The Transitional Care Model was developed to (1) address the negative outcomes 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 National Institutes of Health (NIH)-funded randomized controlled clinical trials (RCTs), 6, 7, 8 TMC has achieved significant and sustained outcomes:
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Avoidance of hospital readmission and emergency room visits for primary and co-existing conditions. TCM has resulted in fewer rehospitalizations for these patients' primary illnesses as well as their coexisting conditions. Additionally, among those patients who require rehospitalizations, the time between their primary discharge and readmission is longer and the number of inpatient days is generally shorter than expected.
* Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauley M. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120:999-1006.
** Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauley MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620.
*** Naylor MD, Brooten DA, Campell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684. -
Improvements in health outcomes after discharge. Improvements in physical health, functional status, and quality of life have been reported by patients who received TCM.
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Enhancement in patient and family caregiver satisfaction. Overall patient satisfaction has increased among patients receiving TCM. In ongoing studies, TCM also aims to lessen the burden among family members by reducing the demands of caregiving and improving family functioning.
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Reductions in total (i.e., physician, hospital, and home health) health care costs. Both total and average reimbursements per patient have been reduced in TCM focused randomized controlled clinical trials.
* Total costs were calculated based on the number of, timing of, and reasons for hospital readmissions, ED visits, unscheduled acute care visits to physicians, and care provided by visiting nurses or APNs and other healthcare personnel.
** Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauley MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620.
*** Naylor MD, Brooten DA, Campell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
TCM Complements Other Important Health Care and Social Services
A number of more traditional services for the chronically ill are provided by hospitals, home care agencies, and disease management programs for the chronically ill. Support services provided by home- and community-based waiver programs play an important role in providing care to the sub population also eligible for Medicaid. Several other models of care have been developed that include the goal of easing the transition between hospital and home, the "Coaching" 9 Intervention, "Guided Care," 10 and "Medical Home." 11
6 Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauley M. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120:999-1006.
7 Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauley MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620.
8 Naylor MD, Brooten DA, Campell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
9 Coleman EA, Chalmers S. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006; 166:1822-1828.
10 Boult C, Reider L, Frey K, Leff B, Boyd CM, Wolff JL, et al. Early effects of "Guided Care" on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2008; 63(3):321-7.
11 American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. February 2007.