Transitional Care Models

A team perspective on reducing readmission risks

Transitional care models emerged to facilitate safe discharge of high-risk patients. Objectives of transitional care models, timed to post-acute care, are to limit the 30-day readmission risk, avoiding the financial penalty to the discharging hospital, per the Affordable Care Act of 2010. Healthcare systems have approached this challenge in different ways. Settings may range from inpatient rehabilitation facilities, skilled nursing facilities (SNF) to long-term acute care hospitals. There are also programs to support patients at home, with home health agencies.1

Transitional care models are in evolution. Studies have compared the care transition models. There are limited data to support one particular model. Models differ as to which caregiver is best suited to manage or direct the care delivery: advanced practice nurse, RN, or social worker. 2 The focus of this article is from the author’s experience as an APN at a SNF with a transitional care program.

Populations at Risk

Older adults and those with chronic illnesses, such as heart failure, diabetes, strokes, sepsis, and chronic obstructive pulmonary disease, are especially vulnerable to require readmission. Many programs target this population but also may include the person with limited external supports or complex medical needs. Patients learning self-care or new therapy management may benefit from a transitional care stay

SNF Models

The challenge to add a transitional care unit to a SNF is the culture change from a residential community to an environment with increased patient complexity. Since these post-acute patients have an increased risk of complication, the team’s objective is to be attuned to changes and responsive to avoid hospital readmission. In doing so, self-management teaching is part of the goal for home planning. It changes the SNF model of care delivery.

Table 1: Sample Admission Criteria to Transitional Care
From Hospital With Goal of Home
Oxygen flow >5 liters/ new to oxygen
Non-invasive ventilation (bilevel or continuous positive airway pressure)
Newly placed tracheostomy tube with plan for home care
Chest tube with intermittent drain requirements
Peritoneal catheter with intermittent drain requirements
Newly placed ostomy
Newly placed feeding tube
Newly placed feeding tube
 Wounds requiring care
IV line with medication delivery


Reimbursement for the care in SNF is based on the individual’s rehabilitation potential; hence the physical and occupational therapy time drive the reimbursement. The rigors of goals help manage the trajectory of the length of stay. The nursing team care costs are bundled into the daily charges. The effective team creates a culture of shared ownership for outcomes that lead to team planning for care and post discharge.

In the transitional care setting, the ratio of RN to LPN caregivers is typically less than in acute care. A high percentage of care is delegated to unlicensed personnel, often certified nursing assistants. RN leaders can be overwhelmed with the duties of personnel management, resident needs, and operations. Having clinically-focused RNs to appraise the evidence and teach help support teams with best practice care delivery. SNFs affiliated with health systems may utilize evidence-based protocols and standards of care spanning the continuum. The SNF can assure consistency and avoid care fragmentation. This standardizing provides consistency for teaching patients and families the necessary elements of self-management. 3

Plans of Care Components
Medication teaching is a factor in compliance to long-term health maintenance. People with multiple admissions and providers may have a fragmented medication list. Medication reconciliation becomes an important element at the admission to transitional care, and the timing during the stay can be pivotal to understand what may be the home care practice. Having the patient and family bring in the medications from home helps the transitional care team understand what gaps may be evident in knowledge and skill in medication delivery. Looking at how medications are organized, expiration dates and duplicates leads to evidence on compliance. A reconciled medication list at transitional care discharge with teach back from the patient and/ or family can help with accuracy. Providing only prescriptions for new or changed medications can help reduce error. Hand-off information to the primary care providers (PCP) can further validate accuracy. A “see you in seven” policy to set up a primary care appointment within a week can assure the follow-up happens in a timely fashion and the PCP can take on the lead role with further management.

If a person requires the acquisition of skills for dressings and tube care, utilizing the system’s resources for standards of care will assure consistency and evidence. The interdisciplinary team can all contribute to the teaching and demonstration in this format. For example, depending on the transitional care’s resources, a respiratory therapist may begin the teaching for care of a new tracheostomy tube. The nurses can continue the teaching and patient return demonstration as all the team coordinates the plan of care and utilize the evidence for best practice.

Ostomy and wound care may be supported by a certified wound care nurse (WOCN) in acute care, but may not be a resource present at the SNF. Utilizing the resource of consultation, teleconsultation, or standardized clinical practice protocols, the nurses at a SNF can continue the teaching and teach back through return demonstrations.

Nurse practitioners are often providing the routine and acute visits at SNFs. NPs may also contribute to help with interpretation of evidence, as orders are written and via bedside rounding with teams. Care planning rounds are an excellent opportunity for NPs to contribute to the teaching and application of evidence to team members.

Diet teaching can be challenging as the environment is not home. The transitional care team, using an interdisciplinary approach, can provide written information with tools to self-manage the appropriate diet. The dietitian can prescribe the diet and provide the initial teaching. The occupational therapist can utilize those parameters with the kitchen skills of meal prep. The unlicensed nursing team is empowered to assist the patient with medically appropriate diet selections. The nurse can use teach back to validate the acquired knowledge.

The opportunities of teachable moments capture the essence of the team. Making learning with nursing assistants meaningful to their daily practice may enhance a team’s success. Daily weights for heart failure patients may be seen as an unnecessary task that adds to the daily workload. Weight inaccuracy makes clinical decisions a challenge. Enlisting the support of the unlicensed nursing team is pivotal to success. The clinical RN or NP is positioned to teach rationale. The relationship of accurate daily weights at the same time each day, with the same amount of clothing to the management of heart failure: medication dosing, dyspnea, chest pressure, and activity tolerance make it a meaningful task versus “work.” Case examples in team huddles and measures of success with accurate weights and plan changes provide direct correlation of the “why” we do it.3

Nursing students, with rotating clinical sites, can provide the environment to facilitate best practice. Faculty members can provide teaching to clinical teams as the students learn processes within the SNF environment. It is a good opportunity to recruit potential new nursing graduates for future employment on the team.

The social worker’s role in transitional care can vary widely. Planning a transition to home requires team-based planning. With the rigorous planning for complex discharges, the social worker takes a care manager role. The need to plan for home care services, durable medical supplies, and qualification data for some equipment can be best met with a collaborative approach with the social worker and interdisciplinary team. NP and MD providers are often required to sign off and provide the medical authorization. Collaboration and planning assures this is a smooth process for discharge hand off.

Posters and visuals for teaching of new procedures and equipment help the whole team review and gain competency. Vendors can be excellent resources for transitional care to provide supplies and educational resources for teams and patients.

To achieve success for transitional care, the interdisciplinary team needs to own the success or failure. Data review to determine how the team succeeded or drill down for opportunities help teams grow and achieve best practice. Patient stories at huddles can provide learning for how a team contributed to success for a person at home.

Team-Based Care

Transitional care can offer a great transition to home and readmission avoidance. The successful model has not been clearly demonstrated and requires more study. Studies to demonstrate effective models for transitional care are needed to support successful programs. Until data provide recommendations, teams working on supporting a transitional care program can be most successful utilizing the principles of a healthy work environment.4 A clear vision is needed for the program with authentic leadership and effective communication. Within the program, true collaboration promotes positive team planning with acute care teams and within the transitional care interdisciplinary team. Appropriate staffing and resources for patient acuity and needs are achieved with effective decision-making. Meaningful recognition can help teams grow and learn. Developing teams takes time and successful teams share the vision and common goal. Advance practice nurses can be key team members in leading the program planning and system design with innovative healthcare systems, supporting team-based care across the care continuum.


  1. American Hospital Association. Maximizing the Value of Post-Acute Care.
  2. Peikes D, et al. The effects of transitional care models on re-admissions: a review of the current evidence. Generations. 2012;36(4):44-55.
  3. Dambaugh L, Ecklund MM. Transitional care: assuring evidence-based practice in skilled nursing facilities. Clinical Nurse Specialist. 2014; 315-317. doi: 10.1097/NUR.0000000000000083.
  4. Morton P. Creating and Sustaining Healthy Work Environments. Journal Of Professional Nursing [serial online]. 2015;31(3):165-167.

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