Preventing hospital readmissions has become a vexing problem, with 2,600 hospitals receiving penalties from the Centers for Medicare & Medicaid Services this year.
Two University of Pennsylvania nursing faculty members, Mary Naylor and Kathleen McCauley, have set up TransCare Partners, a consulting and educational firm, to bring the Transitional Care Model, an evidenced-based solution, to healthcare facilities across the country.
Transitions are the experiences of patients and families along a journey, and nurses can have a major impact if armed with the right knowledge and skills, said Naylor, PhD, RN, FAAN, professor of gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing in Philadelphia. The Transitional Care Model has helped enormously.
The model entails an advanced practice nurse meeting with the patient daily in the hospital to prepare for discharge, and then visiting the patient at home within 48 hours of discharge. For up to three months after discharge, the APN makes personal visits with the patient and collaborates with the patients providers to arrange whatever is needed, whether it be transportation, a ramp for access and egress or a medication change to meet the patients goals.
Naylor first developed the model 20 years ago, and she and colleagues have been researching it with different populations ever since. In a 1999 article in the Journal of the American Medical Association, she reported that 24 weeks post-discharge, 20% of patients receiving the TCM intervention were readmitted, compared to 37% receiving standard care.
A 2004 study involving older heart failure patients found TCM patients had 104 readmissions at 52 weeks compared to 162 in the control group. In translating the model to use with at-risk Aetna Medicare Advantage members, TCM reduced rehospitalizations, with 45 of those receiving the intervention being readmitted versus 60 of the matched controls at three months.
We either prevent readmissions or delay the time and keep them out longer, said McCauley, PhD, RN, ACNS-BC, FAAN, FAHA, professor of cardiovascular nursing at UPenn.
Through the years, Naylor and McCauley have worked with other organizations to help them implement TCM.
We dont want to be researchers who do a study [that] goes into a journal, but theres no plan to do it in the real world, McCauley said. We made a conscientious effort to disseminate the model.
Having formed TransCare Partners, the UPenn team will deliver the model to other hospitals, help them develop protocols, and provide 35 hours of webinar training and an operations guide, with all of the assessment forms and other tools needed to successfully transition patients to the home setting.
Debra Anscombe Wood is a freelance writer.