Giving Compass' Take:

• Social Programs That Work identifies the Transitional Care Model as a top tier program, meaning that it is ready to be scaled up and replicated in order to serve the chronically ill effectively. 

• How can philanthropy support this and other effective models? What if any, programs are currently in place to assist chronically ill individuals in your area?

• Learn about the advantages of digital healthcare.

The Transitional Care Model is designed to prevent health complications and rehospitalizations of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up, coordinated by a master’s-level “Transitional Care Nurse” who is trained in the care of people with chronic conditions.  At the time of hospitalization, the Nurse: (i) conducts a comprehensive assessment of the patient’s health status, health behaviors, level of social support, and goals; (ii) develops an individualized plan of care consistent with evidence-based guidelines, in collaboration with the patient and her doctors; and (iii) conducts daily patient visits, focused on optimizing patient health at discharge.

Following discharge, the Nurse conducts periodic home visits and/or scheduled phone contacts with the patient based on a standard protocol.  In Study 1 (below), the post-discharge intervention lasted three months, and included an average of 12 home visits, with no scheduled phone contacts.  In Study 2 (below), it lasted approximately one month, and included an average of 4.5 home visits and weekly Nurse-initiated phone contacts with patients or family caregivers.  In both cases, the Nurse was also available to patients via telephone seven days per week.

Each Nurse handles a caseload of 18-20 patients.  The Transitional Care Model replaces the hospital’s usual discharge-planning and post-discharge activities.  Its cost ranges from $456 per patient (in Study 2) to $1,019 per patient (in Study 1), in 2010 dollars.

Results:

30-50% reduction in rehospitalizations, and net savings in health care expenditures of approximately $4,500 per patient, within 5-12 months after patient discharge.

Read the full article about the Transitional Care Model at Social Programs That Work.