OpenPlacement Blog

Which Care Transition Model is Best?

Care transition models play a huge role in lowering readmissions. Patients, families, and medical providers depend on these models to answer the “What, When, and Who” during a deterioration in a condition after being discharged. Hospitals have developed these models to point out to patients and their caregivers what red flags to look out for in their medical condition, when to make that call, and who to contact to attain appropriate care. Due to a fragmented healthcare system, the models have provided solutions in unifying medical providers into one system so patients receive timely and non-repetitive aftercare. I have looked into five current care transition models and outlined their differences to help you determine which is best.

Coleman Care Transitions Intervention (CTI)**:**

This model is based on the work by Eric Coleman, MD. Through hospital partnerships with geriatric transitional communities such as Skilled Nursing Facilities (SNFs) and Adult Services, the CTI program has organized an initiative to prevent readmissions. This is accomplished by designating nurses or social workers as “transition coaches” who will track patients four weeks after their hospital discharge to train and prepare patients in self-care. Efforts to tighten up follow-up care have developed to fill educational gaps in medication management and recognizing signs of deteriorating conditions. As a financial benefit, “transition coaches” can decrease readmissions by providing better surveillance of the aftercare as well as reassure anxious patients who may not feel ready to leave the hospital.

Guided Care (Johns Hopkins):

Johns Hopkins has developed their own care transitions program replacing “transition coaches” with “guided care nurses” (GCNs). Focusing on primary care practices, physicians and GCNs team with patients to manage care outside of the clinic. The Guided Care program places emphasis on the available online training for both physicians and nurses as well as a supplemental program for caregivers. Nurses are eligible for a Certificate in Guided Care Nursing after completing the online course while physicians can earn continuing education credits. Providing access and support for caregivers shows how this coaching program is community-based. GCNs work within the means of the caregivers to find appropriate treatment and resources for the patients. Guided Care is notable for reducing SNF admissions.

Transitional Care Model (TCM):

Developed by Mary Naylor, PhD, RN, FAAN, the Transitional Care Model spans patient care within the hospital to two months of post-discharge homecare. The multidisciplinary care approach is also aimed at reducing hospital readmissions through coordination of after care services by a Transitional Care Nurse (TCN) with pharmacists, therapists, and primary care physicians. With the goal of managing chronic care conditions, the TCM helps those who are not eligible for Medicare's home health benefit by partnering with health insurers such as Aetna. Currently the TCM is being utilized by the RNs and APNs at Kaiser Permanente in Northern CA. On the TCM website there is a section for the "Enhancing Care Coordination in the Presence of Memory and Thinking Problems"( and Delirium Training Modules 2006-2008 UPLOAD.pdf) program, dedicated to supporting and training caregivers of loved ones with cognitive care impairments.

After Discharge Care Management of Low Income Frail Elderly (AD-LIFE):

The AD-LIFE care transitions model determines care according to the Assessing Care of Vulnerable Elderly (ACOVE) guidelines. A sample ACOVE survey can be found here. Integration of an intermediary nurse coach fuels this model as low-income seniors are identified and guided in appropriate rehabilitative after care. Notably different from other care transition models is the collaboration between patient, primary care physician, and the local Area Agency on Aging. Emphasis is also placed on follow-up care by not only the nurse but an interdisciplinary care team as well. Studies are currently being conducted to compare the health functionality of patients with or without a care manager and interdisciplinary team following discharge.

Project BOOST (Better Outcomes for Older Adults through Safe Transitions):

Project BOOST stands out among the care transition programs by offering on-site mentorship to medical professionals. Introduced by the Society of Hospital Medicine, the program functions as a retooled communication platform consisting of handouts documenting the patient care in explicit detail (ie. condition, signs of deteriorating condition, who to call, etc.) and promotion of teach back. The success of the program is attributed to the vast amount of resources provided to BOOST-selected trial sites. In addition to mentor supervision throughout the trial year, BOOST participants have access to a Listserv where a growing community has formed to promote transition care reform.

Each of these care transition models capitalizes on the critical thinking skills of medical providers in finding ways to engage patients in their aftercare. At the forefront of each of these transition initiatives are primary preventative measures such as education and teach back.

However, the number of different care transition models is discouraging. While it is encouraging that hospitals are seeing the benefits of partnering with the long-term care communities, efforts need to be made to create a seamless network of nurses and social workers in both areas to ensure continuity of care. Variation in training (such as GCN versus TCN) may cause confusion in patients who are admitted to care sites that adopt different methodologies of care transition.

In this case, my vote goes to BOOST for investing in creating a network of care providers that can collaborate on best practice for discharge care. Their shared knowledge will most likely translate into a uniform language for patients and families to understand.  This will result in an enhanced understanding of their condition and care that may ultimately decrease readmissions in the long-run. That's my opinion as a health care professional. What's yours?


About the Author

Ninette Tan is an RN with a BSN from Samuel Merritt University. She has two years of experience working on a Rehabilitation floor at an Acute Care Hospital with a focus on discharge planning and follow-up. She values bridging technology and healthcare to create a better discharge process. As a clinical intern, Ninette helps create content for the Open Placement blog and co-manages the social media networks.