Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a systematic review

Abstract

Background Demographic changes are taking place in most industrialized countries. Geriatric patients are defined by the European Union of Medical Specialists as aged over 65 years and suffering from frailty and multi-morbidity, whose complexity puts a major burden on these patients, their family caregivers and the public health care system. To counteract negative outcomes and to maintain consistency in care between hospital and community dwelling, the transitional of care has emerged over the last several decades. Our objectives were to identify and summarize the components of the Transitional Care Model implemented with geriatric patients (aged over 65 years, with multi-morbidity) for the reduction of all-cause readmission. Another objective was to recognize the Transitional Care Model components’ role and impact on readmission rate reduction on the transition of care from hospital to community dwelling (not nursing homes). Methods Randomized controlled trials (sample size ≥50 participants per group; intervention period ≥30 days), with geriatric patients were included. Electronic databases (MEDLINE, CINAHL, PsycINFO and The Cochrane Central Register of Controlled Trials) were searched from January 1994 to December 2019 published in English or German. A qualitative synthesis of the findings as well as a systematic assessment of the interventions intensities was performed. Results Three articles met the inclusion criteria. One of the included trials applied all of the nine Transitional Care Model components described by Hirschman and colleagues and obtained a high-intensity level of intervention in the intensities assessment. This and another trial reported reductions in the readmission rate (p < 0.05), but the third trial did not report significant differences between the groups in the longer follow-up period (up to 12 months). Conclusions Our findings suggest that high intensity multicomponent and multidisciplinary interventions are likely to be effective reducing readmission rates in geriatric patients, without increasing cost. Components such as type of staffing, assessing and managing symptoms, educating and promoting self-management, maintaining relationships and fostering coordination seem to have an important role in reducing the readmission rate. Research is needed to perform further investigations addressing geriatric patients well above 65 years old, to further understand the importance of individual components of the TCM in this population.

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“…However, most readmission reduction programs usually work specifically for certain clinical condition [7]. Since LTHC patients were usually at older age with multiple comorbidities, it is challenging to balance between investments in a readmission reduction effort and readmission cost for homecare providers [8,9]. Risk management predictive models allow home care providers to arrange the priority of medical interventions according to the patient's hospitalization risk and optimize the utilization of medical resources [10].…”

Does a 12-Month Transitional Care Model Intervention by Geriatric-Experienced Care Professionals Improve Nutritional Status of Older Patients after Hospital Discharge? A Randomized Controlled Trial

“…In 1994, Naylor et al developed the Transitional Care Model (TCM) to ensure appropriate and adequate care for older patients transitioning from hospital to home [18]. In this model, transitional care is a set of comprehensive individualized care management strategies carried out exclusively by nurse specialists or trained health professionals to coordinate safe and proper care transitions and ensure continuity of care for patients across the care settings, especially from hospital to home [18,19].…”

David Oliver: The case for transitional post-acute care

“…The term “transitional care,” as defined by the American Geriatrics Society, encompasses a “set of actions and services” to manage the “coordination and continuity of healthcare as patients transfer between different locations,” such as hospitals, nursing and residential homes, the patient’s private residence, and primary and specialty care 12…”

“…In our current climate a focus on better support for patients in those first few days or weeks after leaving hospital, with enhanced capacity in specialty community transitional care, could be a win-win-win for hospital staff, GPs, and patients. It could improve continuity of care and communication, reduce the risk of emergency readmission, help to restore independence,21112 and fill that contested gap between acute and primary care.…”