The Transitional Care Program at a University Health System

Purpose:
The Transitional Care Model is an evidence-based care management approach for older adults moving from the hospital to home. The Transitional Care Nurses work with the patient and family to prevent readmissions, improve health outcomes, enhance the experience with care and reduce costs.

Relevance/Significance:
The program is nursing research driven, using an evidence-based, multidisciplinary approach to improve the health of the population; enhance the health care experience for patients (e.g., quality, access, reliability); and reduce/control costs of care with a specific emphasis on care transitions. Most importantly the TC Program focuses on patient and family caregiver goals while providing continuity across the episode of acute illness.

Strategy and Implementation:
In partnership with the University's School of Nursing, the Health System established the Transitional Care program based on the Transitional Care Model, an evidence-based, nursing researched care management approach proven in multiple clinical trials to improve older adults' care experience, enhance health and quality of life and reduce costs. The program targets high-risk older adults during episodes of acute illness. Guided by an evidence-based protocol, an advanced practice nurse (APN) conducts a comprehensive assessment to determine priority needs and, in collaboration with the patient, family caregivers, and other team members, designs and implements an individualized plan of care focused on optimizing function, promoting self-management and preventing future episodes of acute care. This seven-day/week patient-centered intervention extends from hospital admission to an average of two months post discharge with services delivered and coordinated by the same APN.

Evaluation:
As of January 2015, more than 750 high-risk patients have been enrolled. Findings suggest patients' experience is rated much higher and health outcomes are rated much better pre- to post-Program enrollment. For example among one group of patients we observed the 30 day rehospitalization rate was 9.6%, a figure significantly below the national average.

Implications for Practice:
Our Program is in direct alignment with the CMS priorities (e.g., IHI "Triple Aim") and our Health System's "Blue Print for Quality". The goals are to improve the health of the population; enhance the care experience; and reduce/control costs of care with a specific emphasis on care transitions.