But the model involves more than discharge planning and home care, said TCM developer Mary D. Naylor, PhD, RN, FAAN, a professor of gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania. The first step is for the APRN to help the patient and family set goals during hospitalization. The nurse identifies the reasons for the patient’s instability, designs a plan of care that addresses them, and coordinates various care providers and services.

The APRN then visits the home within 48 hours of discharge and provides telephone and in-person support as often as needed for up to 3 months. Assessing and counseling patients and accompanying them to medical appointments are aimed at helping patients and caregivers to learn the early signs of an acute problem that might require immediate help and to better manage patients’ health care. Also essential is ensuring the presence of a primary care provider. “Patients might have six or seven specialists, but nobody who’s taking care of the big picture,” Dr. Naylor said.

In three randomized controlled trials of Medicare beneficiaries with multiple chronic illnesses, use of the TCM lengthened the period between hospital discharge and readmission or death and resulted in a reduction in the number of rehospitalizations (Naylor et al., 1994, 1999, 2004). The average annual savings was $5,000 per patient.

Until now, transitional care has not been covered by Medicare and private insurers. But the Affordable Care Act sets aside $500 million to fund pilot projects on transitional care services for “high-risk” Medicare beneficiaries (such as those with multiple chronic conditions and hospital readmissions) at certain hospitals and community organizations over a 5-year period. The secretary of the Department of Health and Human Services is authorized to remove the pilot status of this program if it demonstrates cost savings.

Mary Manley relied heavily on her nurse, Ellen McPartland, during her transition from the hospital back to home.

Mary Manley relied heavily on her nurse, Ellen McPartland, during her transition from the hospital back to home.

Now age 85, Ms. Manley takes eight medications regularly, and with the help of Ms. McPartland and a new primary care team is spending more time with family and attending church again. Said Ms. McPartland, “Of all the roles I have had in nursing, this brings it all together. To see them going from so sick to back home and stable—the Transitional Care Model speaks to what nurses really do.”



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