![[ Visit Client Website ]](images/banner.gif)
The Transitional Care Model (TCM) incorporates patient-centered interventions through a nurse-led multidisciplinary team to facilitate beneficial health outcomes for vulnerable populations and promote safe and efficient transfers from one health care setting to another. Patient-centered care interventions are based upon one’s needs, preferences, and values influencing clinical health decisions and self-management. The success of patient-centered interventions is heavily linked to active engagement. The intervention begins in the hospital, extends to the patients’ homes, and ends at the first primary care provider visit after hospital discharge. The TCM was originally intended to provide comprehensive care for chronically ill older adults at risk for poor health outcomes and has successfully decreased emergency department (ED) visits, hospital readmissions, and health care costs. Transitional care not only meets the vast medical needs of vulnerable patients, but also addresses social and cultural needs through a patient-centered, multidisciplinary approach. While the TCM is well-established with positive outcomes, we propose this model can be implemented successfully in a local hospital-owned Transition Center (TC) with a focus on providing patient-centered care with an advanced practice nurse (APN)-led multidisciplinary approach for a younger vulnerable chronic disease population. An estimated 50% of 18-64 year olds have one chronic disease (i.e. heart disease, stroke, cancer, diabetes, obesity, and arthritis) with minority groups leading in multiple co-morbid chronic diseases. Disparities such as low socioeconomic factors, minority status, insurance status, and poor lifestyle behaviors contribute to the development of chronic disease making this sub-population group more vulnerable. Therefore, a quantitative pilot design was conducted comparing the effects of the TCM versus usual care in a local Transition Center on self-management behaviors and health care barriers related to disparities.
Methods:
A sample of 30 subjects was randomized into intervention and control groups. The subjects were recruited from a local private, not-for-profit, large acute care hospital that coordinated care with the hospital-owned Transition Center. All subjects were eligible for TC services before study participation began. The goal of the TC is to provide comprehensive continuum of care for vulnerable chronic disease patients mainly consisting of younger patients without health insurance coverage. All subjects were treated at the center per usual care. In addition, the intervention group received TCM based patient-centered care delivered by a registered nurse in the hospital, their home, and at the first visit to the Primary Care Provider. The registered nurse (RN) focused on physical and social health personalized needs, self-management skills, patient safety, and health care access barriers. Four instruments were used to measure the patient-centered intervention within the TCM and health care barriers pre and post for both intervention and control groups. The Patient Activation Measure (PAM) assesses self-management through self-reported knowledge, skill, and confidence. The PAM is a valid and reliable instrument with 13 questions scored on a scale. A component of self-management is one’s confidence in undertaking behaviors towards improved health, therefore the Self-Efficacy for Managing Chronic Disease 6-item scale (internal consistency and reliability 0.91) was also used for both groups. In order to implement self-management behaviors, one must first be able to obtain, process, and understand basic health information. The Shortened Test of Functional Health Literacy Assessment Scale (S-TOFHLA) was used for both groups as a baseline assessment for health literacy. Finally, the participants’ healthcare barriers are influential elements of disparities contributing to poor health outcomes. Given the fact that the researchers could not find a validated tool to measure health care barriers for the target population, a survey was created based on the Health Care Access Barrier Model (HCAB) incorporating 33 scale and dichotomous questions on financial, structural, and other barriers that afflict the non-elderly adult population.
Results:
A total of 24 participants (12=control, 12=intervention) completed the study. Demographics between the control and intervention groups were middle-aged (mean age 48 vs. 45 respectively), ethnically diverse (58.3% vs. 41.6%), and poor (<$20,000 annual income 91.6% vs. 75%). Both genders were represented as 50% were female in the control group and 66.6% in the intervention group. A portion of both groups had low levels of education (<high school 25% control vs. 33.3% intervention) and 66.6% of the control group was uninsured compared to 75% of the intervention group. Hypertension (25% of both control and intervention groups) and Diabetes Mellitus Type 2 (41.7% control, 50% intervention) were the most reported chronic diseases. Within the intervention group, a mean of 4.30 (SD 1.89) home visits were conducted by the RNs with the length of the intervention lasting a mean of 15.90 (SD 12.64) days. There was a pattern of numerical superiority across the majority of variables. The intervention scored higher than the control group on baseline health literacy (S-TOFHLA) scores (32.3 vs. 31.4) indicating adequate functional health literacy, pre PAM (40.82 vs. 39.45) indicating that they were beginning to take action towards self-management, pre and post self-efficacy (intervention pre/post 46.0, 48.0 vs. 37.1, 44.1 out of a total score of 60) indicating higher confidence towards self-management behaviors, and pre and post healthcare barriers (intervention pre/post 43.4, 46.1 vs. 40.0, 40.7 out of a total score of 99), none were statistically significant. However, the results of the post PAM were significant (CI 95%; p=.002) between intervention and control groups (48.62; SD 2.26 vs. 41.20; SD 5.35) indicating superiority in the intervention group regarding self-management behaviors.
Conclusion:
Given this is a pilot study implementing the TCM, it is promising to find a significant difference on self-management activation with the intervention group post TCM implementation when compared to the control group undergoing usual care. This finding indicates that self-management behaviors and patient engagement is essential for patient-centered interventions which not only improve the quality of care, but can also improve health outcomes. Based on these findings, the investigators will conduct a qualitative analysis on the case notes written by the RNs during the intervention to provide a clearer understanding of the patient-centered care given and it’s impact on the participant. A larger study should also be conducted with more participants, a refined intervention, and include additional outcomes on subsequent emergency room use, hospital readmissions, and quality of life.