Page 546 - Encyclopedia of Nursing Research

TRANSITIONAL CARE n 513

patterns of change that are framed within are at risk for adverse events and, thus, will
predictable spaces of time or could affect be the focus of this entry.
rates and degree of treatment effectiveness. In 1981, a team at the university of T
pennsylvania School of Nursing recognized
Bonnie L. Metzger the need to develop a multidisciplinary
model of transitional care led by master’s
prepared advanced practice nurse special-
ists (clinical nurse specialists or nurse prac-
TransiTional care titioners) to meet increasing health care
costs, decreasing acute care length of stay,
and increasing fragmentation of health
Changes in health care delivery and aging care (Brooten et al., 2002). This model was
of the population during the past 30 years initially designed to deliver care to vulner-
have placed patients increasingly at risk for able low–birth weight premature infants.
adverse events during transitions in care. As The quality cost model of advanced practice
a result of decreased length of stay during nurse transitional care, herein termed TCM,
acute care episodes, changes to payment sys- was subsequently tested with other vul-
tems, and fragmentation among providers nerable populations including women who
across settings, u.S. health care has developed had unplanned cesarean births, pregnant
into an overly complex system. Additionally, women with hypertension and diabetes,
patients are living longer, have increased inci- and the elderly. The elderly, who represent a
dence and prevalence of chronic conditions, high-cost, complex population with multiple
and require more complex care (Institute of chronic illnesses, is a vulnerable population
Medicine, 2001; pham, grossman, Cohen, who has demonstrated the potential to bene-
& Bodenheimer, 2008). Transitional care, fit from transitional care (Murtaugh & Litke,
defined as a set of actions to ensure the coor- 2002; Naylor, 2000, 2004; Naylor et al., 1999;
dination and continuity of health care as Naylor & Van Cleave, 2010).
patients transfer between different locations Research has helped to define and iden-
or different levels of care within the same tify the core components of effective transi-
location, is essential to ensure the coordina- tional care. These evidence-based practices
tion and continuity of health care. Locations include screening for high-risk patients in
for transitional care may include hospitals, need of transitional care services, elucidat-
subacute and postacute nursing facilities, ing patients’ and caregivers’ goals and pref-
the patient’s home, primary and specialty erences, facilitating communication among
care offices, and assisted living and long- providers and across settings regarding the
term care facilities (Coleman & Boult, 2003). essential components of the plan of care,
Studies investigating nurse-directed, multi- educating patients and caregivers regard-
disciplinary, multidimensional interventions ing prevention, early identification, and
have demonstrated the potential for effec- response to worsening health problems,
tive transitional care to improve quality and and placing highly skilled nurses through-
decrease health care costs for older adults at out the transitions to address patients’ com-
risk for poor outcomes (Harrison et al., 2002; plex needs and promote continuity of care
Naylor et al., 1994, 1999, 2004; Schnipper et al., (Naylor, 2006, 2010).
2009; Stewart, Marley, & Horowitz, 1999). The By incorporating these core components,
transitional care model (TCM), developed the TCM has thus demonstrated effective-
at the university of pennsylvania School of ness in three randomized trials for older
Nursing, has demonstrated effectiveness in adults who are at risk for adverse events.
three randomized trials for older adults who These three studies have generated results