The heart of this model is the Transitional Care Nurse, who follows enrolled patients from hospitals into their homes, and using an evidence-based care coordination approach, provides services designed to streamline plans of care and interrupt patterns of frequent acute hospital or emergency department use and health status decline. The Transitional Care Nurse collaborates with patients’ physicians in the implementation of tested protocols with a unique focus on increasing patients’ and caregivers’ ability to manage their care. In published studies of the model, the nurse who implements the intervention is an advanced practice nurse who has a masters degree in nursing with advanced knowledge and skills in the care of older adults.

The Transitional Care Nurse is an expert in providing comprehensive care to the chronically ill, versed in national standards of care delivery, and experienced in providing both acute and community based services. The Transitional Care Nurse provides direction to enhance the effectiveness of the health care delivery team. Both transitions across the physical settings (e.g. acute to community) and transitions in health status are monitored and managed to improve patient care and outcomes. Each nurse manages an active caseload of 15 to 20 patients, with an average of 18 patients. Current TCM demonstration projects are evaluating the use of bachelors prepared nurses and bachelors prepared nurses working in consultation with advanced practice nurses.

• In-Hospital Visit with Patient. In the acute inpatient setting and within 24 hours of enrollment, the Transitional Care Nurse conducts a comprehensive assessment of the patient’s health status and defines priority needs and services for the patient and his/her family/caregiver(s). The Transitional Care Nurse collaborates with the physicians and other members of the health care team to streamline the plan of care and to design and coordinate inpatient care and discharge plans based on the comprehensive assessment and goals identified by the patient.
• Home Visits with Patients. The Transitional Care Nurse visits each patient in his/her home within 24 to 48 hours of discharge from the hospital. After the initial visit, a minimum of one home visit per week during the first month is made, followed by semi-monthly visits until discharge. The Transitional Care Nurse makes telephone contact with the patient as needed and in each week an in-person visit is not scheduled. In addition, the nurses are available to the patients and their family/caregivers by phone from 8am to 8pm Monday through Friday and 8am to noon on weekends. It is important to note that nurses rely on their clinical judgment and each patient’s unique circumstances to determine the actual number and nature of contacts.
  
  Home visits are an essential component of the TCM. The Transitional Care Nurse must see in order to understand how patients and family/caregivers are managing their symptoms, and to be able to appropriately assess their living situation and determine if it is problematic to their health (e.g., the presence of mold in the apartment of a COPD patient; plants that could cause allergies; stressful living conditions). Safety of the patient in completing activities of daily living (ADLs; includes bathing, walking, toileting, etc.) and instrumental activities of daily living (IADLs; includes shopping, housework, etc.) is assessed, recommendations for adapting the environment are made, and referral to area senior agencies are completed if needed.
• Nurse Visit with Physician. The Transitional Care Nurse accompanies the patients on their first visit with the physician post-discharge and on subsequent visits if needed. During the initial visit, the Transitional Care Nurse assures excellent communication related to the plan of care between hospital and primary care providers. For example, the Transitional Care Nurse will provide prior to the visit, or bring with them a copy of the discharge/summary instructions, their own summary on the status of the patient and copies of pertinent tests/labs on an accompanied appointment.
  
  The nurse also helps the patient and his/her family/caregivers to achieve their visit goals. For example, the Transitional Care Nurse assists the patient and family/caregiver to generate a list of questions prior to the physician visit so that the patient can get answers to major questions during the visit. The Transitional Care Nurse directly facilitates and advocates for the patient with the physician. Immediately following the visit, the nurse also assists the patient and family/caregiver in understanding the physician’s instructions.

During an acute care episode, patients retain little of what they have been taught while hospitalized. A great deal of information is communicated to patients and family members during hospital stays, but often the patient is unable to absorb that information because it is such a stressful and vulnerable time. A key element of TCM is the priority on patient and family education. For example, in the first post-discharge visit the Transitional Care Nurse devotes significant time to reviewing the discharge instructions and medication instructions to ensure that the patient really understands and can execute the discharge plan. There is a significant need for “translating” information between the provider and patient to ensure that each really understands what the other has communicated.

Recognizing that home follow-up extends one- to three-months, a significant part of the Transitional Care Nurse’s role is to facilitate the patient and his/her family/caregivers’ ability to manage their care at home. The nurse begins this process with the first hospital visit, working with each patient to identify goals. Across the next one- to three-months, in the home, the Transitional Care Nurse helps the patient develop systems for managing his/her own care effectively and achieving their goals. The Transitional Care Nurse works with the patient and family/caregivers to develop an individualized, realistic plan of care that includes strategies to reach positive health outcomes aimed at preventing future acute care events. A major focal point of the nurse’s efforts is to arm patients and families with the knowledge they need to identify and address health problems early. Each plan is customized and tailored to the individual patient and identifies the resources and level of change that each patient and his/her family/caregivers are willing to accept and execute.

During the patient’s hospitalization, the Transitional Care Nurse reviews the medication plan with all providers including the hospital pharmacist to reduce the overall number of medications and eliminate contraindications and unsafe interactions. At the first post-discharge visit, the Transitional Care Nurse performs medication reconciliation to assure the correct medications, in the correct doses, are present in the home. Patient understanding of changes in medication dosing, brand vs. generic names, and adherence with medications is assured. The Transitional Care Nurse instructs the patient about each medication, stressing its rationale, schedule, side effects, dose in strength and number, and storage. The Transitional Care Nurse assesses the patient’s current system for managing medication and obtaining refills, and suggests changes to medication behavior as needed (e.g., obtaining pill planners, 90 day supply ordering). Each patient’s ability to afford co-payments is assessed; issues surrounding prescription coverage and formulary restrictions are identified; and suggestions for changes to the medication plan, based on coverage, are discussed with the physicians.

TCM is designed to fill an important gap in health care delivery, helping patients make an important transition from the hospital to the home minimizing negative transitions in health status. The purpose of the evidence-based model is not to provide ongoing care to patients but to optimize patient outcomes throughout and following an acute episode of illness. The major goal of this model is to position the patient and family caregivers with the knowledge, skills, and resources essential to prevent future decline and rehospitalization.

At the end of this episode of care, continuity is assured by excellent communication with the primary care providers continuing to follow the patient who has made a commitment to his/her self-management goals. In some cases, the Transitional Care Nurse will help facilitate access to palliative care or hospice services, assisted living, or chronic case management, based on the individualized needs of the patient and his/her family/caregiver. A discharge summary prepared by the Transitional Care Nurse is provided to the patient and the primary care provider who will assume responsibility for continuing care. The patient’s goals, progress in meeting these goals, and ongoing or unresolved issues with the plan of care are addressed in the summary.

The Penn research team developed a web-based clinical information system that houses all of the assessment tools, intervention protocols, and the Omaha System, a standardized language for documenting patient problems and nursing interventions. The system is also used to track the patient’s visits, medications and symptoms and delivers evidence-based protocols to the point of care.

Web-based training modules are offered to nurses in conjunction with the clinical information system. The core modules rely on a case study, independent instructional learning format with interactive modules that enable ongoing exchanges with multidisciplinary experts. Two module sets are available—one aimed at transitional care with cognitively intact patients; the other on care for cognitively impaired patients.