In the context of health care services, nurses play an important role in strengthening public health, preventing diseases, and rehabilitation. The role of nurses is extremely great in modern health care for elderly people since the former make decisions in the field of management and organization of patients’ health outcomes. This paper will reflect the key findings regarding the transitional care model (TCM) in elderly patients with chronic and other conditions. Each of the research questions posed in the previous phases will be answered separately to provide a clear presentation of results that were collected from patients, their families, and nurse professionals.
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In order to assess the quality of the transitional care model, the researcher conducted the study, questioning patients, their families, and nurses of the local environment and those who are treated both at home and in the hospital. The questionnaire consisted of 20 questions and included data on the participant, including sex, age, education, etc. as well as a block of questions about the amount of nursing assistance provided, an opinion on the work of nurses, the quality of nutrition, the conditions of care, and proposals for improving the quality of nursing care. Totally, 300 respondents participated in the study, namely, 100 participants composed each of the mentioned groups.
The majority of patients were people over 50 years old – 57 percent, and the rest is older than 60. Among the respondents, 47 percent were male, and 53 percent – female. Less than half (45 percent) of patients were not the first time on treatment at the chosen hospital. The majority of respondents (82 percent) were familiarized with the transitional care model.
On the other hand, a significant part (18 percent) of patients remained unaware. The reason can be either in the inattentiveness of nursing professional or in the lack of them. The overwhelming majority of respondents highly appreciated the quality of the model – 89 percent that indicates a good professional preparation of nurses. 11 percent of those who were dissatisfied with the quality of health care delivery can be conditioned both by the psychological features of the patients and by the incompetent actions of the nursing staff. At the same time, the mentioned facts reveal the effectiveness of the transitional care model.
Additional Interventions and Activities
The researcher also asked the following question: can any additional interventions and activities make the model more effective? This question was suggested to answer to patients, their families, and nurses. In order to emphasize key results, the answers were integrated. Since many respondents gave several answers, the total number of marked items is 215. Of these, the most popular are caring for chronically ill patients focusing on living basics – 47 percent and manipulation – 30 percent.
Furthermore, there is communication – 10 percent of respondents noted the need for more attentive communication at the hospital and home. Such a gradation, in the researcher’s opinion, is quite natural, since most of the respondents are well aware of the problem. The next most important answer is preventive work – 11 percent noted it. Finally, the need for promotion of health was specified by two percent of participants. Of the ten people who think otherwise, only one commented, pointing out the need for psychological help.
In patients of geriatric age, the lack of the identified additional interventions led to the limitation of mobility and self-care. Therefore, in combination with good adequate treatment, there should be the same proper care, including physical exercises, diet, sleep and wakefulness, various medical procedures, help with administration, prevention of pressure ulcers, constipation, hypertension, etc. (Hirschman, Shaid, McCauley, Pauly, & Naylor, 2015). Only good care can facilitate and help in improving the health condition of a patient.
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When caring for patients of elderly age, the majority of nurses reveal their awareness and compliance with the norms of nursing ethics and deontology that are of special importance. Often a nurse becomes the only close person to a patient, while each of them needs an individual approach, taking into account the patient’s personal characteristics and attitude towards the disease.
The Lack of Specialized Skills in Nurses Providing Transitional Care Model
As for the skills of nurse professionals, the results were approximately the same, yet with slight variations: 78 percent consider that the lack of specialized skills is critical to provide transitional care model in elderly patients, paying attention to the peculiarities of such care. General care for elderly patients is always complicated and requires much attention and time. The respondents stated that the most significant in care for elderly patients is respect for their personality along with understanding and acceptance of their physical and mental issues.
To properly organize care for patients, a nurse needs to know the age features of their behavior. For example, older people become more sensitive and vulnerable and react with fear or depression to the difficulties or changes in their life. Elderly patients also suffer a severe change in the direction of diminishing their physical and mental functions. Therefore, the majority of patients believe that only a competent nurse can help them with their needs. Among the most essential skills a nurse should have, the respondents emphasized openness, health promotion, honesty, integrity, communication, and awareness of the needs of elderly patients.
In their turn, nurses pointed out that they try to encourage elderly patients to self-care. If an elderly person keeps an eye on his or her appearance, regularly shaves, combs, and changes clothes, it always raises his or her mood and helps improve the overall condition. They state that proper nutrition is important for the elderly and especially chronically ill patients. In them, the intensity of metabolic processes in the body is reduced, so it is necessary to reduce the calorie content of food by decreasing the content of fats and carbohydrates (Naylor, Hirschman, O ‘Connor, Barg, & Pauly, 2013). However, it was revealed that nurse professionals pay less attention to patients’ families and their role in care delivery. In particular, only 38 percent of surveyed nurses pointed out that they continuously communicate with patients’ families and promote the importance of their care. The rest of the nurses focus on inpatient care and/or prefer to educate patients themselves.
The increased occurrence of readmission patterns was noted due to the lack of proper skills in nurses. For example, such cases as the inability to provide post-discharge nutrition, the postponed dressing, and inadequate reactions to patients’ needs were noted. As stated by Jackson et al. (2015) in their study related to transitional care and readmissions, “patients receiving transitional care had a significantly lower readmission rate, regardless of whether the index hospitalization was for a medical or a psychiatric reason” (p. 225).
Similar results were revealed in this study as well. More to the point, Jackson, Trygstad, DeWalt, and DuBard (2013) reveal the same tendency in the research that shows the significant reduction of readmissions due to the implementation of the transitional care model in North Carolina. It should also be stated that the presence of two or more chronic diseases in one patient complicates the situation and increases the risk of readmission.
On average, when examining a patient of the elderly age, specialists reveal at least five diseases. In this regard, the clinical picture of the diseases cannot be completely clear, and the diagnostic value of various symptoms decreases. What is more, concomitant diseases can reinforce each other. For example, one of the patients noted that his anemia caused clinical manifestations of heart failure and led to readmission. In general, the majority of patients and their families emphasize the role of nurses’ specialized skills as well as the ability to properly use them in practice.
Limitations of the Transitional Care Model with Regard to Elderly Patients
Another question was asked about the limitations of the transitional care model. In the answer graph, there were six variants, among which the first four involved positive traits, and the others – negative ones. All the respondents gave several answers to the question, so the total number of answers was 215. In the aggregate of responses, 79 percent of respondents highly appreciated nurses caring for them or their relatives. However, five of the patients noted indifference to them from their nurse, which, most likely, is the action of a specific nurse, which once again confirms the need to improve the personnel policy. Among other answers, there were the following ones: fulfills the doctor’s prescriptions satisfactorily, provides necessary services, etc.
From the above statistics, it becomes evident that the key limitation of the model is its nurse-centered nature. In other words, the transitional care model largely depends on nurses and their competence that causes the need for their continuous training and awareness of the situation. In particular, it was noted that discharge and post-discharge care especially lacks the adequate level of competence, since nurses cannot deal with such issues as home-related services, including help with daily problems. While caring for elderly patients in the hospital environment, they provide living basics of eating, dressing, transferring, and so on, patients stress that they tend to experience difficulties with the mentioned issues. It is then possible to suggest that there is a need to update the model of transitional care by developing a more detailed and comprehensive plan of follow-ups and controlling their timely delivery (Naylor, 2012).
At the same time, the study results indicate insufficient involvement of family members in the process of post-discharge care for elderly patients. Some of them (30 percent) are unaware of the fundamental needs of such patients, while others (20 percent) cannot provide these services adequately, since they were not instructed by a nurse, thus lacking the required skills and competence. As a result, elderly patients have to face problems with their everyday needs due to the nurse-oriented nature of the given model. It seems essential to emphasize that both patients and their families expressed some assumptions regarding the implementation of the transitional care model. They noted that it would be better if a nurse provided more training to them, educating the fundamental aspects of home care, key activities, and recommendations.
Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2015). Continuity of care: The transitional care model. The Online Journal of Issues in Nursing, 20(3).
Jackson, C. T., DuBard, A., Swartz, M., Mahan, A., McKee, J., Pikoulas, T.,… Lancaster, M. (2015). Readmission patterns and effectiveness of transitional care among Medicaid patients with schizophrenia and medical comorbidity. North Carolina Medical Journal, 76(4), 219-226.
Jackson, C. T., Trygstad, T. K., DeWalt, D. A., & DuBard, C. A. (2013). Transitional care cut hospital readmissions for North Carolina Medicaid patients with complex chronic conditions. Health Affairs, 32(8), 1407-1415.
Naylor, M. D. (2012). Advancing high value transitional care: The central role of nursing and its leadership. Nursing Administration Quarterly, 36(2), 115-126.
Naylor, M. D., Hirschman, K. B., O ‘Connor, M., Barg, R., & Pauly, M. V. (2013). Engaging older adults in their transitional care: What more needs to be done? Journal of Comparative Effectiveness Research, 2(5), 457-468.
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