Adapting Transition Models: A Hospital-Wide Evolution

The COVID-19 pandemic has forced hospitals to adapt their operational models to balance epidemic control with economic recovery. This has resulted in an especial transition phase between emergency and regular modes of operation. Hospitals have had to implement temporary rotation plans for staff, increase ICU capacity, and improve testing and isolation procedures. In addition, hospitals have adopted transitional care models to improve patient outcomes and reduce readmission rates, especially for chronically ill older adults. These models focus on providing multidisciplinary, evidence-based clinical protocols to enhance patient experiences and improve health and quality-of-life outcomes. The Transitional Care Model (TCM), pioneered at the University of Pennsylvania, has been adapted and tested with various populations and has shown promising results in reducing hospital readmissions and total care costs.

Transition from child to adult care

In the medical world, the term "transition" refers to the process of preparing young people to become consumers of adult healthcare. During childhood, parents are responsible for ensuring their child's medical needs are met, but as they grow older, it becomes increasingly important for them to manage their own healthcare. Healthcare transition focuses on building independent healthcare skills, such as self-advocacy, preparing for the adult model of care, and transferring to new healthcare providers.

Transition planning can occur in multiple settings, and youth with disabilities, chronic conditions, or special healthcare needs may have several transition teams. These teams can include healthcare providers, parents, and other adults who can offer recommendations based on their experiences. It is important to consider the policies and age limits of the pediatric/adolescent practice, as well as the youth's ability to make decisions about their healthcare.

To support this transition, resources such as tip sheets, toolkits, and virtual summits are available to help youth and their families plan for the youth to assume greater responsibility for their healthcare. These resources can provide information on topics such as medical insurance coverage, financial assistance, and transferring to new healthcare providers.

The Transitional Care Model (TCM) is a nurse-led intervention designed to improve the outcomes of patients transitioning from hospital to home, particularly those with chronic illnesses or multiple hospital visits. The model aims to reduce hospital readmissions and enable patients and their caregivers to manage their conditions effectively. While originally designed for older adults, TCM has been adapted for other populations, including individuals with intellectual and developmental disabilities.

Reducing hospital readmissions

Hospitals have adapted various transition models to reduce readmissions and improve patient outcomes. These models focus on improving care coordination, patient education, and transitional care interventions. Here are some key strategies and models that have been effective in reducing hospital readmissions:

Transitional Care Management (TCM)

Transitional Care Management (TCM) is a critical approach to reducing hospital readmissions. TCM focuses on improving care coordination and providing follow-up care, medication management, and patient education. It offers a structured framework to enhance patient engagement and outcomes. The implementation of TCM has been shown to decrease the likelihood of hospital readmissions, improve patient satisfaction, and reduce healthcare costs.

Mary Naylor's Transitional Care Model

This model, designed by Mary Naylor, is a nurse-led intervention specifically targeting chronically ill older adults who are at high risk of readmission. It involves a period of interventions lasting 1-3 months, during which an advanced practice registered nurse (APRN) performs a pre-discharge assessment and develops a transitional care plan in collaboration with the hospital team. The APRN provides multiple home visits, telephone outreach, and accompanies the patient to their first primary care follow-up visit. This model emphasizes patient engagement, goal setting, and communication with all stakeholders.

Care Transitions Intervention Model (Coleman Model)

The Coleman Model is a 4-week program that aims to foster patient engagement and smooth transitions from the hospital to home. It includes a transition coach who focuses on the patient's self-identified goals and helps develop self-management skills. The coach describes the transitional care program, obtains consent, and provides support during the hospital stay and transition.

Better Outcomes for Older Adults (BOOST)

BOOST is another model mentioned in several sources that aims to improve outcomes for older adults and reduce readmissions. While specific details of this model are not provided, it appears to be effective in reducing readmission rates.

Standardizing Discharge Processes

Hospitals have recognized the importance of standardizing discharge processes and improving care transitions. This includes developing comprehensive discharge planning, ensuring effective communication between healthcare providers, and addressing breakdowns in communication. Standardizing discharge processes can help identify patients at high risk for readmission and improve patient education and clinician accountability.

Interprofessional Collaboration and Primary Care

Implementing interprofessional, primary care-based TCM programs has been shown to reduce readmission rates at 30, 60, and 90 days. Engaging patients with primary care providers and ambulatory care services improves post-hospitalization outcomes and reduces readmissions throughout the post-discharge follow-up period.

Transitioning from hospital to home

To reduce adverse events and prevent readmissions, successful information transfer from clinicians to patients and their families is crucial. This includes educating patients and their families about the patient's condition, the discharge process, and the next steps, in clear and plain language. Additionally, discharge planning should involve discussing key areas to prevent problems at home and providing clear care instructions.

Before discharge, it is essential to prepare the patient's home environment to enhance their comfort and safety. This may include rearranging furniture to ensure ease of movement, cleaning to promote health, and setting up any necessary medical equipment, such as a hospital bed or oxygen equipment. It is also important to display emergency numbers and health provider information in a prominent place.

Furthermore, it is vital to be realistic about the challenges that may arise during the transition. As such, caregivers should be honest about the level of care they can provide and should not hesitate to seek guidance and resources from the hospital staff. Understanding the basics of prescribed medications and receiving clear instructions from hospital staff can help ensure the patient's safety and health.

SafeMed model for high-risk patients

The SafeMed model is a transition model that uses a primary care-based team approach to make transitions safer for high-risk and high-needs patients, reducing hospital admissions and emergency department visits. The model was developed by the University of Tennessee in partnership with Methodist Le Bonheur Healthcare in Memphis and is based on a winning entry in the AMA-MGMA Practice Innovation Challenge.

The SafeMed model uses a team that includes physicians, pharmacists, nurses, and community health workers to form a support network for high-risk patients. The team works closely with patients to build strong relationships, making it easier to coordinate and manage their care. The model addresses complex medical and social problems and uses Licensed Practical Nurses (LPNs) and pharmacy technicians as community health workers. These workers act as both nurse and pharmacist extenders, obtaining medication histories, assisting in medication reconciliation, and identifying potential drug therapy problems (DTPs). They also reinforce medication education, ensuring patients understand their medication regimens.

The SafeMed program starts with a daily report that informs the clinic of patients who have been hospitalized in the last 24-72 hours. The nurse leader then determines which patients could benefit from SafeMed care transition support, and home visits by community health workers are scheduled. These workers meet with the SafeMed team, including the physician, pharmacist, and nurse leader, to address medication issues or care management problems identified during home visits.

The SafeMed approach can be adapted by individual practices to reduce drug therapy problems and improve overall patient health. It involves developing a care transitions plan, identifying complex patients who are good candidates for the program, and assembling and training the SafeMed team. This includes selecting a leader to designate team leads and hiring any additional staff required. The SafeMed model is one of several models aimed at improving transitional care, with others including the Transitional Care Model (TCM) and BOOST ("Better Outcomes for Older Adults Through Safe Transitions").

Multidisciplinary approach for chronic diseases

During the COVID-19 pandemic, hospitals have had to adapt their operations to deal with the emergency and impaired healthcare access for patients with conditions other than COVID-19. This has led to a transition phase, where hospitals have implemented temporary rotation plans for staff, improved access to mental health services, and increased ICU capacity.

In terms of chronic diseases, a multidisciplinary team approach (MDTA) has been proven to be the most effective way of managing patients with complex pathologies. This approach has been successfully applied in fields such as primary healthcare, oncology, diabetes, and cardiovascular and chronic kidney diseases. The MDTA involves a close collaboration between various dedicated physicians and specialists, such as infertility and maternal-fetal medicine specialists, obstetricians, paediatricians, transplant physicians, geneticists, and psychologists. This team-based approach ensures better coordination and management of patients with multiple chronic conditions, improving patient outcomes and reducing hospital readmissions.

For example, in the case of women with solid organ transplants who desire children, an MDTA is mandatory to minimise risks during pregnancy. Similarly, for patients with multiple chronic conditions, such as heart disease, diabetes, chronic obstructive pulmonary disease, and mental illness, a multidisciplinary team can provide coordinated care and improve overall management.

The Transitional Care Model (TCM), a nurse-led intervention, is another example of a multidisciplinary approach designed to improve the outcomes of chronically ill older adults transitioning from hospital to home. The TCM utilises evidence-based clinical protocols to prevent health declines and reduce hospital readmissions. It also empowers patients and their caregivers to manage their conditions more effectively, reducing the need for frequent hospital visits.

In summary, the transition model adapted by hospitals during the COVID-19 pandemic focused on emergency response and gradual recovery. Simultaneously, hospitals continued to implement multidisciplinary approaches to manage chronic diseases and improve patient care, demonstrating the importance of coordinated strategies in healthcare.

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