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Interdisciplinary and Transitional Care Models


There are a lot of different models of care delivery in nursing, which is explained by the fact that healthcare units have their specific needs and must adapt their practices to be able to satisfy all of them. Therefore, deciding which model to select largely depends on its ability to provide high-quality solutions to all the existing problems of the organization (Cherry & Jacob, 2016).

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Historically, there were four basic nursing care models:

  1. functional;
  2. team nursing;
  3. total patient care;
  4. primary nursing.

While the first two are more task-driven, the last two are more patient-oriented. However, already in the 1980s, non-traditional models began to appear, providing unprecedented solutions (Cherry & Jacob, 2016).

It is important to understand that nursing models encompass a wide variety of inpatient setting issues and are not restricted to the work of nurses. They should take into consideration ambulatory care, home care, pharmacy services, social work, staff organization, etc. This accounts for the importance of the proper selection of the model by each health care unit.

Interdisciplinary Care Model

In my nursing practice settings, the interdisciplinary care model is the one typically observed throughout the unit since it is believed that it makes all members of the staff feel involved and work closely in cooperation with all departments.

The basis of the interdisciplinary care practice model lies in the interprofessional competency of the whole hospital team. The idea is that all health professions must be able to collaborate, interact, and integrate care they provide in order to achieve the highest quality. This allows using a complex mix of expertise and knowledge since people of different health care occupations enrich one another’s the background.

Lancaster, Kolakowsky‐Hayner, Kovacich, and Greer‐Williams (2015) refer to this model as “an orchestra model.” The parallel is that in an orchestra, each member has a different stock of knowledge, skills, and talent and hears music from his/her own perspective. However, only working together, musicians are able to produce a cohesive performance that will be satisfying to the audience. Enhanced patient care should rely on the same principle: Everyone should work together to provide high-quality, patient-centered care. Unfortunately, most of the time, nurses, physicians, and UAPs act as if they were separate care providers that have not related to one another’s practice.

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Furthermore, it is quite common for all of them to perceive themselves as the major and unique decision-makers. They establish hierarchical relationships and communicate only for a brief consultation, avoiding substantial discussions. Yet, it has been proven that since these professionals have to work together, coordination of their roles is inevitable as it is the only way to avoid errors of judgment and fragmentation of treatment.

Effective interdisciplinary communication eliminates misunderstandings, conflicts, and tension that appear due to differences in opinions. It is crucial for health care units to step away from their hierarchical structure and acknowledge the fact that all members of the care delivery team make their contribution to achieve the common goal. It is not about competition but about cooperation, respect, and support.

Another study on the topic proves that the interdisciplinary care model not only improves working conditions facilitating communication between professionals but also allows improving the self-care ability of patients and decreases the number of emergency visits. The researchers found out that if patients are provided with hospital rehabilitation, discharge planning, management of malnutrition, falls, and depression prevention consultations, and in-home follow-up care, their self-care ability improves significantly. This allows them to avoid emergency visits and readmission. They have better performance trajectories due to enhanced rehabilitation provided collectively by different health care professionals (Shyu et al., 2016).

Transitional Care Model

A different nursing model that is worth discussing (since it provides a valuable alternative) is transitional care model. It was created to prevent complications and readmissions of patients by providing detailed and personalized discharge planning and in-home care. Yet, unlike the first model, transitional care approach requires master’s degree in nursing as it usually involves working with people who are chronically or terminally ill. The nurse must be able to conduct and accurate assessment of the patient’s current status of health, his/her habits, social position, values, goals, attitude to treatment, etc. and provide an individual plan of care based on daily visits (Cherry & Jacob, 2016).

Weerahandi et al. (2015) conducted a research to find out whether this model is capable of reducing costs of care and readmissions. The problem is that there is little evidence on the influence produced by care coordination programs based on transitional care model on hospital utilization. The researchers conducted a retrospective cohort study to find out the effects of a continuous follow-up care. They discovered that readmission rate was reduced by 34% while hospitalization rate decreased by 22%. Furthermore, inpatient costs were $900,000 lower.

Another study conducted by Naylor et al. (2013) supports this evidence. It assessed the status of patients that received follow-up care and compared cost outcomes. It was found out that all patients participating in the study showed improved quality of life indicators and health status as compared to those who received pre-intervention therapy. In three months, a considerable decrease in readmission rates was observed (45 vs. 60 re-hospitalization cases). The use of transitional care model was also associated with a health care costs decrease (by $439 per member per month). These findings demonstrate that the model is effective indeed and can be successfully translated into practice.

Implementation of Interdisciplinary Care Model

From my personal observations of the way interdisciplinary care model is implemented, I singled out the following integral parts of this process:

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  1. First and foremost, the implementation begins with the leader who is to establish the direction for the whole team. All team members must have a clear vision of what they are doing before the start. The leader also clarifies vague points, provides supervision and support.
  2. When values and goals are identified, it is necessary for the team to set clear and comprehensible objectives and develop a plan of actions to achieve them since every member must know what to do.
  3. It is worth mentioning that from all my observations I concluded that the model is implemented more effectively when a team culture is fostered through consensus and trust. It is important both in the planning and the action phase to make staff see that all contributions and opinions are valued.
  4. Another important aspect is to build lasting infrastructure that would facilitate communication. When the model is translated into practice, team members must be sure that they have all necessary tools to communicate without obstacles.
  5. For the model to bring about positive changes, staff members must document all outcomes and utilize feedback from other professionals in their practice.
  6. I noticed that the implementation of the interdisciplinary model heavily relies on autonomy and individual role. It is wrong to perceive it as relegating your duties to other people since interdependence does not mean less responsibility.
  7. Finally, I also paid attention that in my hospital settings leaders did not provide appropriate training for the staff to be able to translate the model into practice. Moreover, most staff members did not realize what rewards and career opportunities they will have. I believe that this aspect needs improvement.

Recommended Model

If I had to recommend a different model of care delivery that would allow improving safety, personnel satisfaction, and general quality of care, I would opt for progressive patient care (PPC). This model presupposes placing patients in units according to the degree of the disease they have as well as their dependence on nurses (Cherry & Jacob, 2016). Thus, all nursing and other medical needs of patients are taken into consideration, which means that the right patient receives the right care at the right time.

It increases safety since it is known in advance which threats may appear in which group. That makes it possible to develop detailed prevention strategies. The quality of nursing care is improved through narrow specialization. The same is true about staff satisfaction: Each member of the staff knows exactly how to deal with this or that group of patients. This gives a sense of competence and achievement.

Conclusion: Personal Reflection

Doing the assignment, I learned that there is no universal model of care delivery that will suit all hospitals. This variety is inevitable since all patients, departments, and care units have different needs and requirements. The choice of the model is a non-random one as it will determine the direction of activities of all members of the staff, not only nurses. If the model is selected correctly, it will improve staff satisfaction, increase safety, and facilitate all interactions with patients, who will have higher chances to avoid readmissions.


Cherry, B., & Jacob, S. R. (2016). Contemporary nursing: Issues, trends, & management. Amsterdam, Netherlands: Elsevier Health Sciences.

Lancaster, G., Kolakowsky‐Hayner, S., Kovacich, J., & Greer‐Williams, N. (2015). Interdisciplinary communication and collaboration among physicians, nurses, and unlicensed assistive personnel. Journal of Nursing Scholarship, 47(3), 275-284.

Naylor, M. D., Bowles, K. H., McCauley, K. M., Maccoy, M. C., Maislin, G., Pauly, M. V., & Krakauer, R. (2013). High‐value transitional care: translation of research into practice. Journal of Evaluation in Clinical Practice, 19(5), 727-733.

Shyu, Y. I. L., Liang, J., Tseng, M. Y., Li, H. J., Wu, C. C., Cheng, H. S.,… Yang, C. T. (2016). Enhanced interdisciplinary care improves self-care ability and decreases emergency department visits for older Taiwanese patients over 2 years after hip-fracture surgery: A randomised controlled trial. International Journal of Nursing Studies, 56(1), 54-62.

Weerahandi, H., Basso Lipani, M., Kalman, J., Sosunov, E., Colgan, C., Bernstein, S.,… Egorova, N. (2015). Effects of a psychosocial transitional care model on hospitalizations and cost of care for high utilizers. Social Work in Health Care, 54(6), 485-498.

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