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Transitional Care Model Implementation Phase

The Transitional Care Model (TCM) is an intervention aimed at the reduction of risk for negative health outcomes among older adults that move between and across health care settings (Hirshman, Shaid, McCauley, Pauly, & Naylor, 2015). Evidence-based health care management approach, which lies at the core of the model, allows nurses to focus on “identification of patients’ health goals, design and implementation of a streamlined plan of care, and continuity of care across settings and between providers throughout episodes of acute illness” (Hirshman et al., 2015, p. 3). Moreover, the TCM helps to promote patients’ satisfaction by maintaining a high level of communication and transmission of health care information among different units and clinicians participating in the transferring process.

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The aim of this paper is to outline the key components of the implementation phase of the project. It will present a detailed description of the implementation process and provide a time frame of the project. Moreover, the paper will address the issue of evaluation of the implementation of the TCM with the help of transitional care components. The paper will also discuss statistical tools required.


In order to successfully implement the TCM, it is necessary to continuously measure how its core components are applied. Patient outcomes and resource use are other essential elements of the implementation process that have to be measured in order to ensure full operational potential and sustainability of the TCM (Toles et al., 2012). For measuring success of the implementation of the TCM, the following core components will be used: screening and staffing, relationships maintenance, engagement of patients and their family members; assessment and management of risks, education and promoting of self-management, collaboration, promotion of continuity, and coordination (Hirshman et al., 2015). Even though these elements of the transition process are defined separately, it is important to remember that in aggregate, they create a holistic care process. Rigorous evaluation of the implementation process with the help of the nine core components will help to substantially reduce rehospitalisation rates of older patients. Moreover, it is expected that assessment of the implementation of the TCM will reduce health care costs by eliminating costs of extra intervention (Hirshman et al., 2015).

Statistical Tools

In order to assess the adherence to the nine core components, standard tools for evaluation of cross-cutting metrics will be used. They will help to benchmark the adoption of core components of the model in a situation when not all elements can be applied due to a limited nature of resources such as EHRs. Moreover, benchmarking will help to ensure that adaptation of the core components does not reduce benefits of the TCM model. In order to evaluate cross-cutting metrics, it is necessary to conduct a set of analytical procedures such as ANOVAs, variance analyses, and regressions among others (Faltin, Kenett, & Ruggeri, 2012). To this end, Statistical Package for the Social Sciences (SPSS) will be used as a statistical software solution. It will help to efficiently manage and organize cross-cutting metrics as well as produce well-structured reports containing selected datasets and parameters. Graphical user interphase of the package will make it easier to navigate the process of analysis (Faltin et al., 2012).


In order to measure the success of the implementation of the TCM model “a stepped-wedge cluster randomized clinical trial design” (Muntinga et al., 2012, p. 8) will be used. The design is “a type of cluster randomized trial design involving sequential roll-out of an intervention to primary care practices (clusters) over a number of time periods” (Muntinga et al., 2012, p. 8). The intervention in the design is the TCM model practices will be compared with usual care practices in a control group. It will help to ensure full operational potential and sustainability of the model, thereby substantially improving the quality of life of older adults.


The implementation of the TCM model is dependent on the notion of self-regulation among nursing and clinician teams. Therefore, a research team will be responsible for the creation of theoretical and practical material for interventions. After the key routines and protocols predicated upon sound knowledge and professional experience have been developed, nursing and clinician teams will start implementing them without interventions from the research team. The key step in the implementation of the TCM is the education of health care professionals (Burke, Kripalani, Vasilevskis, & Schnipper, 2012). Therefore, members of nursing teams will participate in a customized training program. The program will include 2-day motivational interviewing courses and the Resident Assessment Instrument (RAI) workshop (Muntinga et al., 2012). Almost all budget needs associated with the implementation of the program stem from the necessity to cover education expenses. Patient visits will require additional costs.

Prior to the start of the implementation of the TCM, nurses will receive “a training on the job motivational interviewing session as well clinical education on geriatric topics provide by the expert team staff” (Muntinga et al., 2012, p. 7), which will help them to better understand complex care needs of older patients. It is an essential component of the model because the training program covers all challenges in elderly care, thereby allowing health care professionals to ensure patient safety and satisfaction. The topics of the training program will be tailored according to the information obtained from RAI reviews. Four months into the implementation of the TCM, all involved health care team members will participate in a refresher RAI workshop.

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The success of the implementation process is predicated on the performance of three TCM elements: quality management, transfer of knowledge, the creation of care networks. Quality care management will be based on the following components: regular team meetings, education sessions and workshops, and multidisciplinary reviews of patients (Muntinga et al., 2012). It is essential that training and education sessions and workshops are held on a regular basis; therefore, they will be conducted every four months. This approach to education will help to create “a platform for peer supervision and encourage knowledge exchange between nurses” (Muntinga et al., 2012, p. 7). If the need arises, additional nurses’ educational needs will be met with the help individual coaching and support sessions. In the case of transferring a complex patient, a team of health care professionals will organize a multidisciplinary consultation during which an interdisciplinary review of a situation will be conducted. The team will consist of a practice nurse, a primary care physician, a pharmacist and members of a geriatric team (Burke et al., 2012). Other health care professionals will be invited to join the consultation team in extremely complex cases.

In order to effectively conduct transfer management, geriatric teams will “set up and maintain regional networks of local organizations” (Muntinga et al., 2012, p. 7). It will help to promote the coordination between different health care organizations in the region, health care providers, and community-based establishments. Members of these organizations will regularly meet and discuss the coordination of care of older adults during transfers.

Geriatric Assessments

Regular geriatric assessments conducted by practice nurses will help to establish health care needs of older patients and create tailored care plans. The assessments will be conducted with the help of two home visits. The first visit will involve the identification of care needs through the multidimensional assessment with RAI instruments (Burke et al., 2012). The information obtained via RAI assessment will allow nurses to standardize their care routines and will function as a basis for a reminder arrangement for follow-ups. The results of each assessment will be reviewed by primary care physicians for the creation of a customized care plan. During the second visit which will occur in two weeks after the first one, patients will be offered necessary information on treatment options and will be invited to participate in the decision-making process. It will help to place patients’ wishes at the center of a care plan in order to ensure a high level of their satisfaction. Table 1 presents the time frame of the project.

Table 1

Time Frame of the Project

Motivational interviewing courses Day 1-2
RAI workshop Day 3
Team meeting Week 1
The creation of local and regional networks Week 2
A refresher RAI workshop Month 4
Analysis Month 5


The development of the third phase of the project helped me to better understand steps that have to be taken in order to ensure that the TCM is installed properly. Moreover, the process expanded my knowledge of statistical tools.


Burke, R., Kripalani, S., Vasilevskis, E., & Schnipper, J. (2012). Moving beyond readmission penalties: Creating an ideal process to improve transitional care. Journal of Hospital Medicine, 8(2), 102-109.

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Faltin, F., Kenett, R., & Ruggeri, F. (2012). Statistical methods in healthcare (1st ed.). Chichester, England: Wiley.

Hirshman, K., Shaid, E., McCauley, K., Pauly, M., & Naylor, M. (2015). Continuity of care: The Transitional Care Model. Online Journal of Issues in Nursing, 20(3), 1-12.

Muntinga, M., Hoogendijk, E., van Leeuwen, K., van Hout, H., Twisk, J., Horst, H.,…Jansen, A. (2012). Implementing the chronic care model for frail older adults in the Netherlands: study protocol of ACT (frail older adults: care in transition). BMC Geriatrics, 12(1), 2-10.

Toles, M., Barroso, J., Colón-Emeric, C., Corazzini, K., McConnell, E., & Anderson, R. (2012). Staff interaction strategies that optimize delivery of transitional care in a skilled nursing facility. Family & Community Health, 35(4), 334-344.

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