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Transitional Care Models for Seniors

As the aging population grows, healthcare providers must be proactive in approaches to improve outcomes.

This continuing education offering is sponsored by an educational grant from Innovative Senior Care

To view the Course Outline and take the exam online, click here.

For a printer-friendly version of the exam you can print out, complete and mail to ADVANCE, click here.

Learning Scope #406
1 contact hour
Expires Nov. 5, 2014

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education article is to review the latest information on transitional care models for seniors. After reading this article, you will be able to:

1. List at least three variables affecting the growing burden on the healthcare delivery system.

2. Discuss two aspects of recent legislation which will affect healthcare delivery.

3. Define the concepts associated with transitional care models.

The author has completed a disclosure form and reports no relationships relevant to the content of this article.

There is no doubt about it. The world's populations are aging and people are living longer. More than 9,000 baby boomers turn age 65 every day. Over 85 is the fastest growing age group in the world today. And with advancing age come physical changes and costly acute illnesses with frequent hospitalizations. Today, 5.4 million people are afflicted with Alzheimer's disease and that number is expected to grow to 11 million by the year 2030. Additionally, people over age 65 will account for up to 20 percent of the population by that time.1

As an age group, older adults often suffer from multiple chronic medical conditions necessitating frequent provider visits, changes in medication therapies and increased costs. Age-related changes complicated by progressive physical, emotional and cognitive decline contribute to poorer quality of life, frequent health transitions and the need for multiple providers among many levels of care.2 Confusion regarding care provider recommendations, fragmentation of care and lack of follow through compound the overall treatment plan.

Nationally, hospital 30-day readmission rates for people age 65 and over have been determined to be 17.6 percent with associated Medicare costs of $15 billion.3 Various estimates also note that the majority of lifetime healthcare dollars are spent during the last 2 years of life. These factors contribute to the burgeoning weight on the healthcare delivery system and the massive drain on the Medicare coffers, painting a dismal outlook for future solvency. Adding to that picture are the falling numbers of younger generation workers whose contributions would support survival of the funds.

Healthcare Legislation

In March 2010, the Patient Protection and Affordable Care Act was signed into law mandating that all individuals be covered by healthcare insurance. This controversial act, which is scheduled to be implemented in phases through 2014, focuses on preventive care, prescription drug benefits and enhanced access to healthcare services in the community. A provision in the act addresses methods to reduce healthcare costs through new and innovative processes.

The aim is to protect and improve benefits to seniors and extend the life of the Medicare trust fund. The overall goal is to target waste in the system, reduce costs, improve health outcomes for patients and expand access to high-quality care.4 The far-reaching scope of the act compels insurance companies to charge lower premiums and forces healthcare providers to improve safety measures and services by limiting reimbursements for established metrics not met.

In June 2012, President Obama signed into law the Alzheimer's Act which focused on providing increased funding for research toward prevention and treatment of the disease. Shortly thereafter, Illinois followed with an updated version of a state law to improve access to care and resource utilization for people with Alzheimer's disease and their caregivers ensuring a "dementia-ready state" in the future. Citing preservation of locally based services to meet the needs of older adults with dementia, home and community care resources can be a cost-effective solution to decrease Medicaid costs and prevent premature facility placement.5

Changing Paradigm

What does all of this mean for the taxpayer and the healthcare delivery system? New and innovative ways to provide cost-effective care without sacrificing quality must be considered to meet the needs of the growing elderly population. In November 2011, the Centers for Medicare & Medicaid Services (CMS) announced the Innovation Challenge, to test a wide range of programs across the country to accelerate system-wide health care transformation throughout the nation. This initiative was designed to support a broad spectrum of alternative models of health care delivery and workforce utilization with the goals of providing better health care, better health and lower cost for beneficiaries of Medicare, Medicaid and the Children's Health Insurance Program.6

Legislation, decreased provider reimbursements and the push for innovative practice changes are challenging healthcare organizations to proactively identify gaps in care delivery, safety, efficiency of services and cost-saving measures. The expectation is that the outcome of these challenges and free market ingenuity will ultimately propel healthcare delivery to a new, more efficient paradigm.

Transitional Care Models

To meet these challenges, new models that focus on goals of care and comprehensive planning throughout the continuum for frail and fragile age groups have recently evolved. While some are reminiscent of past replicas, newer service aspects have been incorporated. Moving from a physician-based approach to collaboration among multidisciplinary care providers with a holistic focus, involves family and patients together identifying goals and processes to meet them throughout the life continuum.

Labeled as transitional care models (TCMs), these programs aim to provide comprehensive planning from the hospital to home for chronically ill or high-risk adults. Often nursing driven, the programs are team-based care delivery models designed to increase alignment of the healthcare system with the needs, values and preferences of high risk-individuals and their family caregivers to improve outcomes and decrease costs.2 Additionally, decreasing fragmentation of care through specific systematic processes supports the established individual goals of care. Originally developed in 1981 by advanced practice nurses at the University of Pennsylvania, the TCM program was tested with several vulnerable groups and developed into an exemplar that addresses the needs of chronically ill elderly adults and their family caregivers.2

National programs, such as Project BOOST (Better Outcomes for Older Adults Through Safe Transitions, the Society of Hospital Medicine, seek to improve care as patients transition from the hospital to home. Focusing on the discharge process early and following a comprehensive, systematic approach to targeting high-risk individuals for readmission, the goals are to improve patient satisfaction, information flow to providers at all care levels, mitigate risks for adverse events and enhance education. Utilizing multiple checklists and metrics to measure for success the program has shown consistent benefits.7

Programs such as Project RED (Re-Engineered Discharge) sought to decrease hospital readmissions through better coordination of care on discharge with subsequent home follow up. Following a stepwise approach to coordination of care and patient education, patient readmission rates decreased, quality of life improved and healthcare dollars were saved.8

Most TCMs provide for a comprehensive in-hospital care planning process from the day of admission to discharge. Meeting the patient on day one, trained staff such as nurse care managers or social workers, identify the pre-hospital level of function, co-morbid conditions affecting outcomes, living situation, available family support and expectations for rehab or home care needs at discharge. Anticipating needs early allows for timely interventions and an ongoing evaluation of the goals for care.

The model follows the high-risk, frail patient who suffers from multiple chronic diseases even though the admission diagnosis may have been for a common medical or surgical condition. Limited language skills and education levels as well as a culturally diverse population with questionable access to care often contribute to the needs of these groups. The goals of TCMs are prevention of complications, coordination and continuity of care, and management of medications and treatment plans through a collaborative approach with the patient, family and caregivers at all levels.

Disease management model programs such as those for heart failure concentrate on engaging the patient and family in education and symptom management through close monitoring and coordination of care. Patients are instructed on the value of fluid management, daily weight and dietary changes. Close contact with a care provider via telephone or a weekly visit is part of the program plan. When the patient demonstrates the ability to manage symptoms with little coaching or education, the length of time between follow up is extended. While this type of model is primarily disease specific, TCMs focus on populations at risk with multiple morbidities.

The Care Transitions Intervention Model is a "nurse coaching" program that engages patients in transitioning between care settings by encouraging participation and education to assume a more active self-care approach. Focusing on community dwelling individuals age 65 and older with a number of defined chronic or acute conditions, individuals must reside within a specific geographic area to allow for post-discharge home visits. This model, utilized by numerous organizations, was developed by Eric Coleman of the University of Colorado Health Sciences Center. In a randomized control trial with two separate groups, patients who received education, encouragement and coaching for active self-care management had consistently lower rehospitalization rates at 30, 90 and 180 days compared to the control group.9,10 Utilizing this approach, a group of hospitals in New York recently cut readmissions by 25 percent over 30 days saving healthcare dollars and allowing patients to stay at home and contribute to managing their own well-being through education and coaching.11

Because healthcare services are often fragmented, this model like others, focuses on enhancing the patient's role in their care across all levels, measuring quality, implementing practice improvement interventions and utilizing health information technology to promote safe care transitions. Providing patients with medication list cards to update as needed and discharge checklists to follow prior to transitioning to a new care environment are tools which enhance patient involvement and accountability for their own health.

Strategic to most models are palliative and end-of-life care discussions with goal setting by the patient and family. Recent evidence points to improved quality-of-life measurements when palliative services are utilized as alternatives to risk laden and costly treatments.12 Addressing these issues early allows the patient to express their wishes for care before chronic conditions exacerbate. When given options, patients may choose less aggressive measures as was demonstrated by one research project evaluating residents of skilled nursing facilities.

In this study, two separate cohorts received education which described goals of care preferences, including cardiopulmonary resuscitation, utilizing either verbal or video presentations. In both groups the majority of patients chose comfort measures over more aggressive support.13 Additionally, family members of elderly patients who have died in long-term care facilities prefer open and frequent communication as an essential aspect of satisfaction for all participants at the end of life.14

Value-Based Care

Recent research has demonstrated that adults receive recommended therapies only 55 percent of the time and that an additional 30 percent of care is wasteful and of little value to patients.15 The National Quality Forum (NQF) promotes the development of a high-quality healthcare system which provides effective and efficient care to all Americans through the use of evidenced-based practice measurements with consistent standardized processes.

In 2014, the CMS will reduce base operating payments for diagnosis-related groups (DRGs) to hospitals by 1.25 percent. This reduction of reimbursement will increase consistently through 2017. Outcome measurement standards will become more stringent in pursuit of value and quality. Consumers will have access to organizational performance measurements and the ability to choose providers based on these results. The hospital will be paid for performance and the era of value-based care purchasing will be firmly implanted within the healthcare delivery system.16

Organizations at the forefront of these changes will be those which incorporate processes that include patients and families in care planning throughout the continuum with a focus on optimal outcomes. As noted in the Institute of Medicine's report on the future of nursing, nurses in particular have the opportunity to shape the evolving healthcare environment and delivery of care. Care for older adults will be a growing component of nursing in the future, and our education system must prepare educators and practitioners for that reality.17

Collaborative Approach

As the aging population grows, the economic, legislative and technological environment will change dramatically and healthcare providers must be proactive in approaches to improve outcomes. Doing so through innovative practices that engage patients, caregivers and providers through a collaborative approach addressing individual wishes and goals for care may be the best option to ensure quality of life at all levels.


1. Alzheimer's Association 2012 Alzheimer's Disease Facts and Figures (2012). Alzheimer's & Dementia, 8(2), 1-72.
2. Naylor, M. (2012). Advancing high value transitional care: The central role of nursing and its leadership. Nursing Administration Quarterly, 36(2), 115-126.
3. Watkins, L., Hall, C., Kring, D. (2012). Hospital to home. Professional Care Management, 17(3), 117-123.
4. The Affordable Care Act: Implementation timeline. Retrieved Oct. 18, 2012 from the World Wide Web:
5. Public Act 97-0768. July 13, 2012. Retrieved Oct. 18, 2012 from the World Wide Web:
6. We can't wait: Health Care Innovation Challenge will improve care, save money, focus on healthcare jobs. Nov. 14, 2011. Retrieved Oct. 18, 2012 from the World Wide Web:
7. Boosting care transitions. Society of Hospital Medicine. Retrieved Oct. 18, 2012 from the World Wide Web:
8. Project RED (re-engineered discharge). Retrieved Oct. 18, 2012 from the World Wide Web:
9. Coleman, E., Parry C., Chalmers, S., et al. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives Internal Medicine, 166(17), 1822-1828.
10. Coleman, E. (2011). What will it take to ensure high quality transitional care? Retrieved Oct. 18, 2012 from the World Wide Web:
11. Singer, P. (July 9, 2012). Program shows reduction in hospital admissions. Democrat and Chronicle. Retrieved Oct. 18, 2012 from the World Wide Web:
12. Gaertner, A., Wolf, J., Voltz, R. (2012). Early palliative care for patients with metastatic cancer. Current Opinion in Oncology, 24(4), 357-362.
13. Volandes, A., Brandeis, G., Davis, A., et al. (2012). A randomized controlled trial of a goals-of-care video for elderly patients admitted to skilled nursing facilities. Journal of Palliative Medicine, 15(7), 805-811.
14. Jackson, J., White, P., Fiorini, J., et al. (2012). Family perspectives on end of life care: a metasynthesis. Journal of Hospice and Palliative Nursing, 14(4), 303-311.
15. National Quality Forum, Improving Healthcare Quality. Retrieved Oct. 18, 2012 from the World Wide Web:
16. Studer Group. The pay for performance era is here. Retrieved Oct. 18, 2012 from the World Wide Web:
17. A Summary of the February 2010 Forum on the Future of Nursing: Education. Institute of Medicine, 1-89.

Online Resources
Healthcare and You:
National Institutes of Health:
National Institute on Aging:

Sue E. Durkin is an advanced practice nurse, clinical nurse specialist at Advocate Good Samaritan Hospital, Downers Grove, IL.

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