Applying the Transitional Care Model in Caring for Older Adults with Heart Failure
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Abstract
Quality improvement of continuing care service has been recognized as the key strategy for reducing the mortality rate, readmission rate, and cost among older adults with
heart failure. The Transitional Care Model is a continuing and comprehensive nursing process, aimed at supporting patients and family caregivers to transition from the illness phase into the convalescence phase smoothly. This article aims to explain concepts and components of the model,
and its application in caring for the older adult group through developed intervention program. Transitional care nurses play a major role in creating an individual transitional care plan. The care plan included 9 nursing activities and 2 phases of care; in-hospital phase and post-discharge phase in order to respond effectively to clients’ health needs.
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References
Naylor MD, Bowles KH, McCauly KM, Maccoy MC, Maislin G, Pauly MV, Krakauer R. High-value
transitional care: translation of research into practice. J Eval Clin Pract 2013; 19(5): 727-33.
Laugaland K, Aase K, Barach P. Interventions to improve patient safety in transitional care a review of
the evidence. WORK 41 2012; 2915-24.
Coleman EA, Smith JD, Frank JC, Min S, Parry C, Kramer AM. Preparing patients and caregivers to
participate in care delivery across setting: The care transitions intervention. J Am Geriatr Soc 2004; 52:
-24.
Coleman EA, Parry C, Chalmers S., Min S. The care transition intervention: results of randomized
controlled trial. Arch Int Med 2006; 166: 1822-8.
Intarasombat P, Monkong S, Churaitatsanee S, Vongterapak S, Prasanatikorm W, Pornsawatchai P,
et al. Comprehensive care of hospitalized older adults: transitional care from hospital to home. RNJ 2013;
(2): 194-205. [In Thai]
European Society of Cardiology (ESC). 2021 ESC Guidelines for the diagnosis and treatment of acute
and chronic heart failure of the European Society of Cardiology (ESC). Eur Heart J 2021; 42(36): 3599-
https://doi.org/10.1093/eurheartj/ehab368.
Chunharas P, Yingchoncharoen T, Kunchorn RA. Heart Failure Council of Thailand (HFCT) Heart
Failure Guideline. Medical Association Cardiology of Thailand 2019. Nextstep Design Limited
Partnership. [In Thai]
Naylor MD, Brooten DA, Campbell RL, Maislin GM, McCaule KM, Schwartz JS. Transitional care of
older adults hospitalized with heart failure: A randomized clinical trial. J Am Geriatr Soc 2004; 52(5):
-684.
Boltz M, Capezuti EA, Zwicker D, Fulmer T. Evidence-based geriatric nursing protocols for best
practice. 2021. 6th Editions; New York: Springer Publishing Company, LLT.
Liu E, Lampert BC. Heart failure in older adults: medical management and advanced therapies.
Geriatrics 2022; 7, 36.
Butrous H, Hummel SL. Heart failure in older adults. Can J Cardiol 2016; 32(9): 1140-7.
Naylor MD. Transitional care for older adults: a cost-effective model. LDI of Health Economics 2004;
(6): 1-4.
Ortiz MR. Transitional care: nursing knowledge and policy implication. Nursing Science Quarterly
; 32(1): 73-7.
Naylor MD. A decade of transitional care research with vulnerable elders. J Cardiovas Nurs 2000; 14(3):
-14.
Toles M, Colon-Emeric C, Naylor MD, Barroso J, Anderson RA. Transitional care in skilled nursing
facilities: a multiple case study. BMC Health Services Research 2016; 16(186): 1-14.
Hirschman KB, Shaid E, McCauley K, Pauly MV, Naylor MD. Continuity of care: The Transitional
Care Model. OJIN 2015; 20(3): 1.
Rezapour-Nasrabad R. Transitional Care Model: Managing the experience of hospital at home. Electron
J Gen Med 2018; 15(5): em73
Morkisch N, Upequi-Arango LD, Cardona MI, van den Heuvel D, Rimmele M, Sieber CC, et al.
Components of the transitional care model (TCM) to reduce readmission in geriatric patients: a
systematic review. BMC Geriatrics 2020; 20(1): 345.
Bixby MB, Konick-McMahon J, McKenna CG. Applying the Transitional Care Model to elderly
patients with heart failure. J Cardiovasc Nurs 2000; 14(3): 53-63.
Poungkaew A, Boontein P, Tongsai S, Charoenyos N, Tanutpokeenun L. Factors predicting quality of
life among patients with heart failure. Thai J of Cardio-Thoracic Nurs,2020; 31(1): 179-97. [In Thai]
Lertpongpakpoom S, Phongphet C, Suwanno J. Predictors of readmission after one-year hospital
discharge with acute decompensated heart failure. Thai J of Cardio-Thoracic Nurs 2019; 30(2): 126-40.
[In Thai]
Ba HM, Son Y-J, Lee K, Kim B-H. Transitional care interventions for patients with heart failure: An
integrative review. IJERPH 2020; 17:2925 doi:10.3390/ijerph17082925
Yuan L, Fu MR, Luo B, Zheng H. The effectiveness of Transitional care interventions on health care
utilization in patients discharges from the hospital with heart failure: A systematic review and meta-
analysis. J Am Med Directors Assoc 2021, 22(Issue 3): 621-9.
Rhiantong J, Malathum P, Monkong S, McCauley K, Viwatwongkasem C, Kuanprasert S. Outcomes of
an advanced practice nurse-led continuing care program in people with heart failure. Pacific Rim Int J
Nurs Res 2019; 23(1): 32-46. [In Thai]
Kedchai W. The effects of the Transitional Care Model for heart failure patients, Kingnarai hospital. J
Nurs Health Care 2020; 38(4): 73-82. [In Thai]