The Transitional Care Model is a nurse-led model

The Transitional Care Model

The Transitional Care Model is led by nurses. The strategy was created with the goal of reducing re-hospitalization and health consequences in chronically unwell senior individuals. To do this, the framework demands that patients receive a detailed discharge plan as well as a follow-up process coordinated by a transitional care nurse. The nurse in issue must have a master's degree and the necessary training to care for people with chronic illnesses (Hendrix et al., 2013). Several actions are carried out by the nurse during the inpatient stay. The transitional care nurse, for example, provides a full assessment of the patient's health status, social support level, health behavior, and goals. Additionally, the patient is impacted with the obligation of establishing an individualized care plan which abides with evidence-based guidelines while collaborating with the patient and the doctors. Furthermore, the nurse is also expected to carry out daily patient visits which are aimed at optimizing the patient’s health during the time of discharge.

Concepts and Principles behind the Transitional Care Model

Various concepts and principles bind the Transitional Care Model. For example, the concept of continuity of care is mainly evident in the presented model. Apparently, the framework focuses on establishing effective strategies which are focused on improving on the care outcomes and transitions for the elderly people who are diagnosed with various chronic conditions. It is also evident that the Transitional Care Model is nurse-led and its main target is the older adults who are at risk for poor outcomes when they move across varied healthcare settings. The model is bound by various principles which define the care delivery approaches. According to Watson et al. (2011), the care delivery approaches which target Triple Aim includes improved health of the established population of the elderly, improving on the patient experiences, and reducing costs. When it comes to the evidence based transitional care offered to the target population, time limited services offered which is offered at the time of the acute illness is not considered as the approach which improves on the care administered to the older adults.

Issues Related to Care Transitions

Various issues are related to the transition of care in different levels of care. Cost problems is one of the issues noted in such a case scenario. Boutwell, Johnson and Watkins (2016) indicate that cost problems associated with the use of two levels of care arise in various instances. For example, when the person who should receive a high level of care are replaced within a skilled nursing facility. Additionally, the cost of care can arise in the case where the patients available at various levels of care are less costly to care for in comparison to the average number of patients in a facility.

Quality problem is also a major issue related to care transition. Research has indicated that quality will always suffer in cases where the residents receive limited services in relation to their noted medical condition (Shaw et al., 2014). similar to the problem of cost, it is evident that the incentive of the providers under varied levels of classification system has the tendency to encourage the aspect of “under service” particularly in large facilities. It is also a fact that the instance of under-service may also take place in cases where the public programs do not enforce the standard of care as required or when the standards in question are also low. An imprecise level of care distinction can also contribute towards under-service in various ways. For example, it is a fact that the standards of care for each level can be set based on the average economic capabilities of the members available in the presented categories. As a result, the persons available in the noted level in question may not receive appropriate services even in a facility where the standards of input are satisfied while the persons in the available levels are not correctly classified.

Access problem is also another issue in this case. It is a fact that establishing various levels of care impedes medical care access. In cases where a rate is assigned to each medical facility, the cost of administering care for the noted persons in the identified category with above-average needs is not reimbursed fully. It is apparent that reimbursements are insensitive to cost variations at various cost levels hence establishing incentives which reduce access particularly for the elderly within each care level. In cases where the identified persons must wait to be admitted to nursing homes, the general cost of the public budget increases while the quality of their life become even more affected.

How Transitional Care Model Increases Care Continuity

The Transitional Care Model can increase continuity of care by identifying the requisite strategies focused on improving the care outcomes and transitions. It is apparent that older adults faced with multiple chronic conditions can face even difficult health related concerns which are complicated by varied risk factors such as deficits in activities or social barriers hence making management of their healthcare needs even more complicated. The Transitional Care Model ensures continuity of care by identifying the effective strategies which improves on the outcomes and care transitions of the identified population. The model also focuses on reducing costs of health care hence making it possible for the members of the identified population to access the presented services at any point in time without much strain. The Transitional Care Model also increases continuity since it focuses on establishing a comprehensive plan of discharge and follow-up which is accomplished by the Transitional Care Nurse.

The Role of Transitional Care Nurses

Transitional care nurses have an important role to play when it comes to the coordination and management of patient care. Incidentally, the nurses within the presented category have the responsibility of moving patients from a single care setting to another. Bumpus (2016) provides that transitional care is composed of a broad range of environments and services designed to promote a timely and safe passage of patients between various levels of care available over various care settings. High-quality transitional care is highly important for older adults who are diagnosed with multiple chronic conditions or are undergoing complex therapeutic regimens. The transitional nurses are required to offer constant care to the identified group of individuals more frequently. The presented fact is based on the assumption that the persons in question are vulnerable to care breakdown as therefore highly in need of the transitional care services.

The transitional care nurses have a role to play in supporting the older adults during their hospitalization period as well as after hospitalization to ensure that their distinctive needs are addressed at any point in time during their transitions in care. The Transitional Care Nurse also has a significant role to play in conducting an assessment on the health of the patient including social support and health behavioral changes. With this, the nurse will find it easier to manage and prevent further health problems which may put the health of the patient at further risk. Apparently, the nurse is allowed to make adjustments on the administered therapies offered to the patient therefore ensuring an increased level of care delivery.

The transitional care nurses also have a role to play in conducting follow-up sessions after the patient is discharged. The nurse can accomplish the presented role by making phone call follow-ups or constant visits to the patient in question. As a result, it will be easy to identify any changes on the patient’s health hence managing the condition becomes even much easier.


To conclude, a Transitional Care Model is highly effective in ensuring continuity of care to the elderly patients who are diagnosed with chronic conditions. Through the help of a transitional care nurse, the outlined framework contributes significantly towards continuity of care delivery even after the patient is discharged from a medical facility. The transitional care nurse is impacted with various roles and responsibilities which he/she must achieve to prevent instances of re-hospitalizations of the patients in question. For example, during the period of hospitalization, the nurse is required to conduct assessments on the patient’s health to reveal any changes hence making the process of managing the condition even easier. After discharge, the nurse is expected to take part in follow-up processes to ensure the patient is abiding by the presented therapies and medication hence preventing re-hospitalization.


Boutwell, A. E., Johnson, M. B., & Watkins, R. (2016). Analysis of a Social Work-Based Model of Transitional Care to Reduce Hospital Readmissions: Preliminary Data. Journal Of The American Geriatrics Society, 64(5), 1104-1107.

Bumpus, S. M. (2016). Cost Analysis of an Advanced Practice Registered Nurse Transitional Care Model for Cardiac Patients. Nursing Economic$, 34(5), 236-254.

Hendrix, C., Tepfer, S., Forest, S., Ziegler, K., Fox, V., Stein, J., & ... Colon-Emeric, C. (2013). Transitional Care Partners: A hospital-to-home support for older adults and their caregivers. Journal Of The American Association Of Nurse Practitioners, 25(8), 407-414.

Shaw, K. L., Watanabe, A., Rankin, E., & McDonagh, J. E. (2014). Walking the talk. Implementation of transitional care guidance in a UK paediatric and a neighbouring adult facility. Child: Care, Health & Development, 40(5), 663-670.

Watson, R., Parr, J. R., Joyce, C., May, C., & Le Couteur, A. S. (2011). Models of transitional care for young people with complex health needs: a scoping review. Child: Care, Health & Development, 37(6), 780-791.

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