Transitional Care Management Intervention | Free Essay Example

Transitional Care Management Intervention

Words: 1221
Topic: Health & Medicine

Transitional Care Management (TCM) is seen as an effective tool to decrease the rate of readmissions in patients with CHF. The TCM often involve some services provided within a month after the discharge but this period is rather long. This paper dwells upon an intervention that involves the provision of specific TCM services 14 days after patients’ discharge.

Change Model Overview

The John Hopkins EBP Process provides nursing professionals with a framework for implementing the change. The process of change consists of three major stages (PET) (Schaffer, Sandau, & Diedrick, 2012). First, the nurse should identify the question to be addressed (practice question). The second stage implies searching, summarizing and developing recommendations concerning the change (evidence). The third stage involves the development of an action plan, the implementation of change and delivering findings (translation). Nursing professionals will benefit from the use of this approach as they will have a specific framework for the implementation of change.

Practice Question

Step 1: Recruit Interprofessional Team

It has been acknowledged that multidisciplinary teams are particularly effective when it comes to TCM (Vedel & Khanassov, 2015). Different healthcare professionals have the necessary knowledge of the peculiarities of the patient, which enables them to deliver high-quality services associated with positive outcomes. The team will include a physician, a cardiologist, pharmacist, and an ANP performing the role of the visiting nurse.

Step 2: Develop and Refine the EBP Question

The EBP question can be formulated as follows: Do TCM appointments (held 14 days after the hospital discharge) decrease chances of hospital readmission in adult patients suffering from CHF? As for the PICO elements, the target population (P) is adult patients with CHF who have been discharged from the hospital within 14 days. The intervention (I) is an appointment held within 14 days after the patient’s discharge. The C element (comparison) can be patients who do not have such an appointment. The desired outcome (O) is the decrease in the number of readmissions.

Step 3: Define the Scope of the EBP

It has been estimated that about 20% of patients with heart failure are readmitted within a month after their discharge (Kociol et al., 2012). Hospital readmission is a significant problem for the US healthcare system as it leads to considerable losses of funds as these readmissions are often costly Clearly, negative effects of the readmission include financial losses, healthcare staff overload, patients’ health conditions. It is necessary to note that inefficient TCM may lead to the patient’s death if the care is not provided timely (which is often the case in rural areas).

Steps 4 and 5: Determine Responsibility of Team Members

As has been mentioned above an interdisciplinary team can provide efficient TCM services. The cardiologist will provide detailed information on the patient’s state, peculiarities of the disease, possible hazards, and outcomes. The pharmacist will focus on recommendations and consultations concerning medication. The ANP nurse will visit the patient as well as be the major deliverer of care as this healthcare professional will be in the closest contact with the patient and caregivers. The physician will play a coordinative role and provide consultations to the patients concerning a wide range of issue.


Steps 6 and 7: Conduct Internal/ External Search for Evidence and Appraisal of Evidence

This study is supported by a set of quantitative studies. The major strength of this type of research is its generalizability. Quantitative studies provide data that allow researchers to identify whether an intervention can be effective in various settings as trials involving numerous patients are carried out.

Steps 8 and 9: Summarize the Evidence

It has been acknowledged that TCM contributes to the decrease in readmission especially when it comes to moderate- or high-intensity TCM services. Thus, Vedel and Khanassov (2015) note that Transitional Care provided within a month after the hospital discharge is effective although such techniques as phone calls are less efficient as compared to visits and telecommunication.

Feltner et al. (2014) stress that the TCM is specifically effective when multidisciplinary teams are involved. Face-to-face communication is seen as vital. O’Connor et al. (2016) note that such tools as video counseling and instructional videos contribute to the effectiveness of TCM. It is noteworthy that some researchers claim that the efficacy of Transitional Care is somewhat overestimated as the rate of readmission is not very different from cases where patients did not receive TCM services (Kociol et al., 2012). At that, there is still a positive change although it is quite small. Nonetheless, it is clear that a wealth of data shows that TCM is efficient.

Step 10: Develop Recommendations for Change Based on Evidence

It is clear that face-to-face communication (home visits as well as telecommunication using the Internet) is specifically effective and should be used as the basis of the intervention.


Steps 11, 12, and 13, 14: Action Plan

The pilot study will include a number of stages (see Table 1). The first stage will be the preparatory one. Multidisciplinary teams will be created, and the participants will receive a brief training course (with the focus on effective collaboration, development of communication skills and so on). The study will involve all patients with CHF. All patients will receive a TCM schedule, but each of them will be allowed to reject it. The rate or readmission of patients who received and did not receive TCM services will be compared. The study will last for three months. After its completion, the evaluation stage will be carried out. The evaluation of the study will include the analysis of its validity, the rate of readmissions, and some qualitative data (surveys) will be included.

Table 1


Week 1 Week 2 Week 3 Week 4-12 Week 13 Week 14
Teams creation
Teams training
Data analysis
Results delivery

Steps 16 and 16: Evaluating Outcomes and Reporting Outcomes

The desired outcome will be the decreased rate of readmissions of adult patients with CHF. The number of readmissions of patients who received the TCM services will be calculated and compared to the number of patients who refused to receive these services. The results will be reported in a written paper as well as a presentation of major data that will take place during a regular meeting of the staff.

Steps 17: Identify Next Steps

The study will be published in a peer-review article. Some healthcare facilities will be addressed, and the program will be introduced to them. If it is effective, it is possible to encourage other healthcare facilities to adopt the intervention. This can be implemented through healthcare professionals’ associations (especially nursing ones).

Step 18: Disseminate Findings

As has been mentioned above, the findings will be delivered through a written report and oral presentation for the hospital staff. The publication in a peer-reviewed journal, direct contacts with some healthcare facilities and addressing some healthcare employees’ associations will be used to communicate the findings externally.


The intervention plan includes the description of major aspects of the use of TCM services provided within 14 days after the discharge of CHF patients. The major peculiarities of this intervention are the use of multidisciplinary teams and the focus on face-to-face communication with the patient. The plan was developed on the basis of the John Hopkins EBP process, which allowed the researcher to take into account all details and aspects of the problem.


Feltner, C., Jones, C.D., Cené, C.W., Zheng, Z.J., Sueta, C.A., Coker-Schwimmer, E.J.L.,…Jonas, D.E. (2014). Transitional care interventions to prevent readmissions for people with heart failure. Rockville: Agency for Healthcare Research and Quality.

Kociol, R.D., Peterson, E.D., Hammill, B.G., Flynn, K.E., Heidenreich, P.A., Piña, I.L.,…Hernandez, A.F. (2012). National survey of hospital strategies to reduce heart failure readmissions: Findings from the Get with the Guidelines-Heart Failure Registry. Circulation. Heart Failure, 5(6), 680-687.

O’Connor, M., Asdornwised, U., Dempsey, M.L., Huffenberger, A., Jost, S., Flynn, D., Norris, A. (2016). Using telehealth to reduce all-cause 30-day hospital readmissions among heart failure patients receiving skilled home health services. Applied Clinical Informatics, 7(2), 238-247.

Schaffer, M., Sandau, K., & Diedrick, L. (2012). Evidence-based practice models for organizational change: Overview and practical applications. Journal of Advanced Nursing, 69(5), 1197-1209.

Vedel, I., & Khanassov, V. (2015). Transitional care for patients with congestive heart failure: A systematic review and meta-analysis. Annals of Family Medicine, 13(6), 562-571.