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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