scholarly journals Continuity of Care: The Transitional Care Model

2015 ◽  
Vol 20 (3) ◽  
Author(s):  
Karen Hirschman ◽  
Elizabeth Shaid ◽  
Kathleen McCauley ◽  
Mark Pauly ◽  
Mary Naylor
Keyword(s):  
Older Adults ◽  
Transitional Care ◽  
Care Transitions ◽  
Evidence Base ◽  
Management Approach ◽  
Multiple Chronic Conditions ◽  
Care Model ◽  
Healthcare Needs ◽  
Core Components ◽  
Multiple Challenges

Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness. Identifying effective strategies to improve care transitions and outcomes for this population is essential. One rigorously tested model that has consistently demonstrated effectiveness in addressing the needs of this complex population while reducing healthcare costs is the Transitional Care Model (TCM). The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. This article provides a detailed summary of the evidence base for the TCM and the model’s nine core components. We also discuss measuring the TCM’s core components and the overall impact of this evidence-based care management approach.

scholarly journals Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Katherine S. McGilton ◽  
Shirin Vellani ◽  
Alexandra Krassikova ◽  
Sheryl Robertson ◽  
Constance Irwin ◽  
...  
Keyword(s):  
Older Adults ◽  
At Risk ◽  
Cognitive Impairment ◽  
Scoping Review ◽  
Transitional Care ◽  
Community Dwelling ◽  
Multiple Chronic Conditions ◽  
Care Needs ◽  
Delayed Discharge ◽  
Core Components

Abstract Background Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs? Methods The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian’s structure-process-outcome model. Results TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges. Conclusion TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

scholarly journals Cost impact of the transitional care model for hospitalized cognitively impaired older adults

2018 ◽  
Vol 7 (9) ◽  
pp. 913-922 ◽  
Author(s):  
Mark V Pauly ◽  
Karen B Hirschman ◽  
Alexandra L Hanlon ◽  
Liming Huang ◽  
Kathryn H Bowles ◽  
...  
Keyword(s):  
Older Adults ◽  
Transitional Care ◽  
Cognitively Impaired ◽  
Care Model ◽  
Cost Impact

scholarly journals Virtual Geriatric Education Preferences of Rural Social Workers

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 328-328
Author(s):  
Joan Ilardo ◽  
Raza Haque ◽  
Angela Zell
Keyword(s):  
Older Adults ◽  
Rural Communities ◽  
Social Workers ◽  
Online Survey ◽  
Transitional Care ◽  
Healthcare Services ◽  
Multiple Chronic Conditions ◽  
Care Plans ◽  
Health Practitioners ◽  
Geriatric Service

Abstract Older adults in rural communities need access to comprehensive healthcare services provided by practitioners equipped with geriatric knowledge and skills. The Geriatric Rural Extension of Expertise through Telegeriatric Service (GREETS) project goal is to use telemedicine and telehealth to expand geriatric service options to underserved Michigan regions. GREETS educational programs train health practitioners to provide geriatric care for vulnerable older adults. To determine gaps in geriatric competencies, the team conducted an online survey of health professionals including behavioral health practitioners. Respondents identified educational topics and preferred virtual delivery methods. Demographic information included respondent’s professional position, practice setting, and county. The respondents were asked to indicate level of educational need using a scale ranging from a low, medium, or high need. Fifty (47%) of 106 total responses were from social workers. We compared the percent of social workers to other practitioners’ responses in our analysis. Four topics emerged for both groups as medium or high educational needs: 1) transitional care when changing residential settings or post-hospitalization; 2) assisting family caregivers cope with caregiving responsibilities; 3) incorporating community-based services into care plans; and 4) and managing frail older adults. Social workers noted higher need than the other respondents for: 1) managing chronic pain; 2) managing care of patients with multiple chronic conditions; 3) having serious illness conversations; 4) diagnosing dementia; and 5) discussing advance care planning. Both social worker and other respondents indicated interactive case-based webinars; published tools, toolkits, tip sheets; and didactic webinars as their top three learning formats.

scholarly journals Transitions to Long-Term Residential Care Settings

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. 223-223
Author(s):  
Bram de Boer ◽  
Hilde Verbeek ◽  
Joseph Gaugler
Keyword(s):  
Older Adults ◽  
Residential Care ◽  
Transitional Care ◽  
Care Transitions ◽  
Theory And Practice ◽  
Term Care ◽  
Residential Care Facility ◽  
Increased Risk ◽  
The Impact

Abstract During their life course, many older adults encounter a transition between care settings, for example, a permanent move into long-term residential care. This care transition is a complex and often fragmented process, which is associated with an increased risk of negative health outcomes, rehospitalisation, and even mortality. Therefore, care transitions should be avoided where possible and the process for necessary transitions should be optimised to ensure continuity of care. Transitional care is therefore a key research topic. The TRANS-SENIOR European Joint Doctorate (EJD) network builds capacity for tackling a major challenge facing European long-term care systems: the need to improve care for an increasing number of care-dependent older adults by avoiding unnecessary transitions and optimising necessary care transitions. During this symposium, four presenters from the Netherlands and Switzerland will present different aspects of transitions into long-term residential care. The first speaker presents the results of a co-creation approach in developing an intervention aimed at preventing unnecessary care transitions. The second speaker presents an overview of interventions aiming to improve a transition from home to a nursing home, highlighting the clear mismatch between theory and practice. The third speaker presents the impact of the COVID-19 pandemic on transitions into long-term residential care using an ethnographic study in a long-term residential care facility in Switzerland. The final speaker discusses the results of a recent Delphi study on key factors influencing implementing innovations in transitional care. The discussant will relate previous findings on transitional care with a U.S. perspective.

scholarly journals The Experience of Transitional Care for Non-Medically Complex Older Adults and Their Family Caregivers

2017 ◽  
Vol 4 ◽  
pp. 233339361769668 ◽  
Author(s):  
Alexandros Georgiadis ◽  
Oonagh Corrigan
Keyword(s):  
Older Adults ◽  
Family Caregivers ◽  
Information Seeking ◽  
Transitional Care ◽  
Care Transitions ◽  
Care Quality ◽  
Care Staff ◽  
Health Care Staff ◽  
Care Needs ◽  
Diary Data

Transitional care research has mainly focused on the experiences of older adults with complex medical conditions. To date, few publications examine the experience of transitional care for non-medically complex older adults. In this article, we draw on and thematically analyze interview and audio-diary data collected at three hospitals in Eastern England, and we explore the experience of transitional care of 18 older adults and family caregivers. Participants reported mixed experiences when describing their care transitions, which indicated variations in care quality. To achieve independence and overcome the difficulties with care transitions, participants used a range of interrogative techniques, such as questioning and information seeking. We contend that the existing transitional care interventions are inappropriate to address the care needs of non-medically complex older adults and family caregivers. Implications for frontline health care staff and health services researchers are discussed.

scholarly journals Feasibility and preliminary effects of an integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A study protocol

2019 ◽  
Vol 9 ◽  
pp. 2235042X1982824 ◽  
Author(s):  
Maureen Markle-Reid ◽  
Ruta Valaitis ◽  
Amy Bartholomew ◽  
Kathryn Fisher ◽  
Rebecca Fleck ◽  
...  
Keyword(s):  
Older Adults ◽  
Transitional Care ◽  
Pragmatic Trial ◽  
Community Dwelling ◽  
Multiple Chronic Conditions ◽  
Rehabilitation Centre ◽  
Major Life ◽  
Web Based ◽  
Care Intervention ◽  
Hospital To Home

Background: Stroke is a major life-altering event and the leading cause of death and disability in Canada. Most older adults who have suffered a stroke will return home and require ongoing rehabilitation in the community. Transitioning from hospital to home is reportedly very stressful and challenging, particularly if stroke survivors have multiple chronic conditions. New interventions are needed to improve the quality of transitions from hospital to home for this vulnerable population. Objectives: The primary objective of this study is to examine the feasibility of implementing a new 6-month transitional care intervention supported by a web-based app. The secondary objective is to explore its preliminary effects. Design: A single arm, pre/post, pragmatic feasibility study of 20–40 participants in Ontario, Canada. Participants will be community-dwelling older adults (≥55 years) with a confirmed stroke diagnosis, ≥2 co-morbid conditions, and referred to a hospital-based outpatient stroke rehabilitation centre. The 6-month transitional care intervention will be delivered by an interprofessional (IP) team and involve care coordination/system navigation, self-management education and support, home visits, telephone contacts, IP team meetings and a web-based app. Primary evaluation of the intervention will be based on feasibility outcomes (e.g. acceptability, fidelity). Preliminary intervention effects will be based on 6-month changes in health outcomes, patient experience, provider experience and cost. Conclusions: Information on the feasibility and preliminary effects of this newly-developed intervention will be used to optimize the design and methods for a future pragmatic trial to test the effectiveness and implementation of the intervention in other contexts and settings.

scholarly journals What’s Driving SNF Readmission Rates? Exploring Differences in Processes Between High and Low Performing Hospitals

2020 ◽  
Vol 4 (Supplement_1) ◽  
pp. 40-40
Author(s):  
Kirstin Manges ◽  
Roman Ayele ◽  
Marcie Lee ◽  
Chelsea Leonard ◽  
Emily Galenbeck ◽  
...  
Keyword(s):  
Older Adults ◽  
Best Practices ◽  
Acute Care ◽  
Transitional Care ◽  
Care Transitions ◽  
Ethnographic Study ◽  
Nursing Facilities ◽  
Readmission Rates ◽  
Care Processes ◽  
Post Acute Care

Abstract Despite the increasing national focus on improving post-acute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this rapid ethnographic study was to observe processes used to prepare older patients for post-acute care in SNFs, and to explore differences between hospital-SNF pairs with high or low thirty-day readmission rates. We stratified hospitals according to readmission rates from SNF and used convenience sampling to identify two high and two low performing sites and associated SNFs (n=5). We conducted intensive multi-day observations (n=148 hours) and key informant interviews (n=30 clinicians) to describe hospital processes for discharging patients to SNF. We used thematic analysis of interviews and fieldnotes to identify differences in transitional care processes of hospitals discharging patients to SNFs. Hospitals used five major processes prior to SNF discharge that could affect care transitions for older adults: recognizing the need for post-acute care, deciding level of care, selecting SNF facility, negotiating patient fit, and coordinating care with SNF. During each stage, high-performing sites differed from low-performing sites by focusing on: 1) earlier, ongoing, systematic identification of high-risk patients; 2) discussing the decision to go to a SNF as an iterative team-based process; and 3) anticipating barriers with knowledge of transitional and SNF care processes. Identifying variations in processes used to prepare patients for SNF provides critical insight into the best-practices for transitioning patients to SNFs and areas to target for improving care of older adults.

scholarly journals What Predicts Health Care Transitions for Older Adults Following Introduction of LTSS?

2019 ◽  
Vol 39 (7) ◽  
pp. 702-711
Author(s):  
Karen B. Hirschman ◽  
Mark P. Toles ◽  
Alexandra L. Hanlon ◽  
Liming Huang ◽  
Mary D. Naylor
Keyword(s):  
Older Adults ◽  
Health Care ◽  
Service Use ◽  
Care Service ◽  
Care Transitions ◽  
Multiple Chronic Conditions ◽  
Future Health ◽  
Increased Risk ◽  
Health Care Transitions ◽  
Over Time

Objective: To determine predictors of health care transitions (i.e., acute care service use, transfers from lower to higher intensity services) among older adults new to long-term services and supports [LTSS]. Method: 470 new LTSS recipients followed for 24 months. Multivariable Poisson regression modeling within a generalized estimating equation framework. Results: Being male, having multiple chronic conditions, lower self-reported physical health ratings and lower quality of life ratings at baseline were associated with increased risk of health care transitions. Older adults in assisted living communities and nursing homes experienced decreases in health care transitions over time, while LTSS recipients at home had no change in risk. LTSS recipients who had orders to receive therapy, compared with those who did not, had a lower relative risk of transitions over time. Discussion: Predictors of future health care transitions support the need for LTSS providers to anticipate and monitor this risk for LTSS recipients.

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