Healthcare Team Model and Transitional Care


There is a variety of nursing care models, each of them presenting specific attitudes to the process of looking after a patient and reaching the highest patient satisfaction level. All models, despite divergences between them, aim at encouraging nurses to arrange the most favorable working environment, which will inevitably lead to the best patient outcomes (Finkelman & Kenner, 2013). Both traditional and modern nursing care models find their reflection in healthcare settings. The model observed and analyzed in the current paper is the healthcare team model. The paper includes a review and summary of the articles related to the observed care model and another care model. Also, the analysis of observations, recommendations of an alternative approach, and a summary of the experience are described.

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Review and Summary of Articles Related to the Nursing Care Model Observed

The observed care model was the healthcare team model. The two suggested articles are focused on the manifestations of the application of this model in practice. The article by Findley, Matos, Hicks, Chang, and Reich (2014) is focused on the integration of community health workers into the healthcare team. Findley et al. (2014) remark that such workers would make perfect members of the team of specialists working at patient-centered medical homes. However, as scholars note, the methodology of such integration has not been investigated at the appropriate level. Thus, Findley et al. (2014) suggest their observations of the process of integration of community health workers into a patient-centered medical home in South Bronx, New York. The outcomes or research indicate that integration is closely connected with training, recruitment, and supervision by the senior community health worker. According to Findley et al. (2014), when the team understands patients’ preferences, they are able to satisfy customers’ needs better.

Newton et al. (2014) analyze the prospects of interprofessional education research collaboration within the healthcare teams. Interprofessional education is gaining more and more interest in scholars who investigate the possibilities of improving patient care and reaching the best patient outcomes (Newton et al., 2014). Such type of education is defined as two or more professions gaining knowledge from each other in order to enhance their professional skills. Newton et al. (2014) emphasize the need for interprofessional education in nursing care units since different healthcare specialists can obtain some new information from their colleagues that may be useful when taking care of patients.

Review and Summary of Articles Related to a Different Nursing Care Model

The second care model reviewed in this paper is the transitional one. The following two articles are focused on the elements of this model and the ways of its implementation in the healthcare units. Donald et al. (2015) investigate the cost-effectiveness of the delivery of transitional care by nurse practitioners. Scholars notice that, in some cases, the cost of transitional care does not differ much from the cost of other care models. However, Donald et al. (2015) admit that there were some serious limitations to their research, such as small sample size, poor quality of evidence, and weak economic investigation.

The article by Toles, Colón-Emeric, Asafu-Adjei, Moreton, and Hanson (2016) is focused on the peculiarities of transitional care of older adults in specialized nursing facilities. The authors consider transitional care as a productive method for preparing elderly patients for the transition from specialized facilities to homes (Toles et al., 2016). The findings of this article indicate that there are positive prospects of transitional care and that such a care model helps healthcare employees to provide their patients with sufficient information in order to make their transition to home more comfortable.

Observations of the Implementation of the Nursing Care Model and Discussion

In the case that I was able to observe, the healthcare team model was employed. The issues that helped me identify the model were related to the number of people in the team the way they shared the responsibilities. The patient in the case was a 40-year-old man who was admitted to the intensive care unit with acute kidney pain. The patient had chronic kidney disease, and such a type of pain was not an unusual condition in his history of illness. A team of healthcare practitioners immediately started providing help for the patient and performing various operations to relieve his pain. Upon the man’s arrival at the hospital, the registered nurse instructed two nurses to make urine and blood tests and perform an MRI of his abdomen. Upon finding out that the tests were within the norm, the registered nurse prescribed the patient ibuprofen and told another nurse to monitor the patient for several hours. While all of these procedures were performed, another employee was instructed to phone the patient’s family and inform them about his condition. The registered nurse said that if the patient’s condition did not become worse within several hours, he could be discharged.

The actions of the member of the nursing team were prompt and timely. Still, I felt some uneasiness as to the number of people engaged with one patient and the appropriateness and clarity of their roles. It seemed to me that some of the activities might have been done by the same nurse (such as calling the family and monitoring the patient, doing these things one after another). Also, I was quite surprised by the fast discharge of the patient. It seemed to me that he needed to spend more time at the hospital, and his condition should have been observed at least for a day.

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Recommendation of a Different Nursing Care Model

Taking into consideration the condition of the patient, I would recommend employing the transitional nursing care model in the discussed case. The patient has a chronic disease, and having acute pain at such a young age means that the illness may be threatening the man’s health considerably. Therefore, I think that it would be good for the patient if healthcare providers kept communicating with him after discharge. The patient needs advice on how to manage his condition, and he does not seem to be able to cope on his own. Another reason why I would recommend this model is that under the conditions of the transitional model, every member of the nursing team would know their roles and would not perform a variety of functions simultaneously.


Having completed this assignment, I enriched my knowledge of traditional and modern nursing care models. I was able to establish the benefits and limitations offered by two different approaches. The model the implementation of which I observed was rather helpful and effective, but it lacked the coordination between team members and did not offer an explicit division of roles. The suggested alternative care model involves taking care of the patient even after discharge. It has been advocated by researchers that the implementation of the transitional care model can reduce the readmission rates significantly. Therefore, the completion of this assignment prepared me for future practice and will be useful in my professional development.


Donald, F., Kilpatrick, K., Reid, K., Carter, N., Bryant-Lukosius, D., Martin-Misener, R., … DiCenso, A. (2015). Hospital to community transitional care by nurse practitioners: A systematic review of cost-effectiveness. International Journal of Nursing Studies, 52(1), 436-451.

Findley, S., Matos, S., Hicks, A., Chang, J., & Reich, D. (2014). Community health worker integration into the health care team accomplishes the triple aim in a patient-centered medical home: A Bronx tale. The Journal of Ambulatory Care Management, 37(1), 82-91.

Finkelman, A., & Kenner, C. (2013).Professional nursing concepts: Competencies for quality leadership (2nd ed.). Burlington, MA: Jones and Bartlett Learning.

Newton, C., Bainbridge, L., Ball, V., Baum, K., Bontje, P., Boyce, R. A., … Wood, V. (2014). The health care team challenge: Developing an international interprofessional education research collaboration. Nurse Education Today, 35(1), 4-8.

Toles, M., Colón-Emeric, C., Asafu-Adjei, J., Moreton, E., & Hanson, L. C. (2016). Transitional care of older adults in skilled nursing facilities: A systematic review. Geriatric Nursing, 37(4), 296-301.

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