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Transitional Care Preventing Rehospitalization: Study Design


Transitional care is of interest to many researchers and healthcare professionals. There have been numerous attempts to improve current practices in follow-up care. For instance, the Transitional Care Model (TCM) was developed to prevent the rehospitalization of patients with chronic illnesses by ensuring adequate supervision after hospital discharge (Hirschman et al., 2015). Systematic literature reviews have also been conducted to discover common issues presented across many studies over time. This study, however, concentrates on the involved parties instead – nurses, patients, and caregivers. By conducting this investigation, researchers will attempt to identify recurring patterns in current transitional care practices that lead to adverse patient outcomes. The set of provided recommendations will serve as the scientific basis for new follow-up care procedures, regulations, and services.

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Literature Review

A thorough review of the relevant literature was conducted prior to the study. PubMed, Google Scholar, and Medline were used as the primary databases, and search words included “transitional care,” “nursing,” “transitional care model,” “TCM,” “continuity of care,” “family follow-up,” and “limitations.” Studies of both quantitative and qualitative nature were considered. Inclusion criteria were as following:

  • Published within the last five years
  • Written in English
  • Primarily focused on limitations of current transitional care practices
  • Not a literature review

A total of five works was chosen to be used in this study.

Significant effort has been made to study and assess the causes and effects of unfavorable cases of transitional care. Allen et al. (2016) strived to find patterns in patients’ experiences during hospital follow-up. They constructed a framework of four themes that reflect patients’ experience of transitional care as a process of “negotiation and navigation of independence, or dependence” (Allen et al., 2016). Toles et al. (2016) examined the operation of three intentionally chosen skilled nursing facilities (SNFs) and discovered that two of them provided fragmentary transitional care. There were inconsistencies in their services that may result in adverse patient outcomes (Toles et al., 2016). A systematic intervention to the quality assurance processes should be conducted.

The study by Elliott et al. (2016) suggests that transitional care clinics are a potential solution for the improvement of the continuity of care. Robertson et al. (2018) showed that with relevant interventions, it is possible to enhance the quality and safety process of transitional care programs. Naylor et al. (2017) collected the vital concepts and components of quality transitional care services. It can be concluded that the work is being done toward a comprehensive improvement of follow-up care services. While there is a positive effect from ongoing studies and research on the quality, there is still room for improvement.

Methods and Design

The purpose of the study is to analyze transitional care from various points of view and provide a set of recommendations that would help improve the delivery of transitional care to older patients. Because data comes from several distinct groups, namely, patients, nurses, and caregivers, it has to be synthesized to discover answer patterns. Thus, this study uses a descriptive research design with the further synthesis of collected data to describe the current limitations of transitional care services.

A series of one-to-one interviews will be conducted with the members of three groups. The question set will feature both open-ended and multiple-choice questions. For each group, they will be tailored according to their knowledge of transitional care processes and terminology. The data will be processed using a computerized to find general patterns in responses, and narrative synthesis will be conducted afterward. Answers to multiple-choice questions will be entered and analyzed in SPSS software package.

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The interviews will be semi-structured and will take approximately 30 minutes each. They will take place in confidentiality to ensure privacy and no interruptions. In the case of patient interviews, they will be held in locations and settings that are most comfortable for the patient. Each conversation will be transcribed and audio-recorded to secure the accuracy of the data. Transcripts will be compared with their respective audio versions to minimize the chance of human error.


Simple random sampling will be used to avoid bias when choosing target interviewees. However, potential candidates must qualify to be selected for further study – they have to be either a practicing nurse at a facility that offers transitional care services, a patient of age 60 or older that received follow-up care, or a caregiver for such a patient. The search for these people will be done at local healthcare delivery institutions. A total of 30 people will be selected for each group.

Ethical Considerations

To ensure compliance with general research ethics, signed informed consent will be obtained from each participant. Study members will be given a statement that includes all procedures and associated risks written in plain language. Written permission to conduct the study will be received from each hospital where potential participants will be searched at. Any private data that will be received from the participants will not be shared with third parties unless given written consent to do so.


Allen, J., Hutchinson, A. M., Brown, R., & Livingston, P. M. (2017). User experience and care integration in transitional care for older people from hospital to home: A meta-synthesis. Qualitative Health Research, 27(1), 24-36.

Elliott, K., Klein, J. W., Basu, A., & Sabbatini, A. K. (2016). Transitional care clinics for follow-up and primary care linkage for patients discharged from the ED. The American Journal of Emergency Medicine, 34(7), 1230-1235.

Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2015). Continuity of care: The transitional care model. OJIN, 20(3). Web.

Naylor, M. D., Shaid, E. C., Carpenter, D., Gass, B., Levine, C., Li, J.,… & Brock, J. (2017). Components of comprehensive and effective transitional care. Journal of the American Geriatrics Society, 65(6), 1119-1125.

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Robertson, F. C., Logsdon, J. L., Dasenbrock, H. H., Yan, S. C., Raftery, S. M., Smith, T. R., & Gormley, W. B. (2018). Transitional care services: A quality and safety process improvement program in neurosurgery. Journal of Neurosurgery, 128(5), 1570-1577.

Toles, M., Colón-Emeric, C., Naylor, M. D., Barroso, J., & Anderson, R. A. (2016). Transitional care in skilled nursing facilities: A multiple case study. BMC Health Services Research, 16(1), 1-14.

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