Proposed Evidence-Based Change Strategy Change Initiative: Transitional Care Program (TCP)
A transitional care program with a nursing -led model supports patients to read after discharge and support after discharge to increase satisfaction.
Key Components:
- Assign a nurse for transitional care (TCN) to patients at high risk
- Conduct home visits or check -in in the telecommunications neck within 48 hours after discharge
- Strengthen drug farming and self -management education
- Coordinate follow-up appointments
Conscious support: According to Niler et al, nurse -TCP can reduce reduction by up to 30% in older adults. (2017).
Naylor Transitional Care Model
Interprofessional Collaboration Strategy
Nurse leaders need to lead across disciplines to enhance outcomes.
Collaboration Includes:
- Physicians and pharmacists for medication management
- Case managers for social support referrals
- Home health providers for continuity of care
- Health IT teams to facilitate electronic transitions
Benefits:
- Decreased care fragmentation
- Enhanced communication
- Improved patient and caregiver engagement
Outcome Metrics and Evaluation
Success of the TCP will be measured through:
| Metric | Target Outcome |
| 30-day readmission rates | ↓ by 25% in 6 months |
| Patient satisfaction (HCAHPS) | ↑ by 15% |
| Medication reconciliation compliance | 100% within 48 hours |
| Post-discharge follow-up attendance | ↑ to 90% compliance |
Ethical Considerations
- Equity: Make sure the TCP is accessible to underserved populations
- Autonomy: Honor patient choices and consent
- Confidentiality: Protect sharing of patient information using HIPAA-compliant systems
Conclusion
Visionary nurse leadership is needed to lead the future of healthcare. Through the implementation of evidence-based transitional care practices and interprofessional collaboration, nurse leaders can best decrease hospital readmissions and enhance quality of care. This leadership model is not only sustainable but also patient-focused and outcomes-driven
References
- Centers for Medicare & Medicaid Services (CMS). (2023). Readmissions Reduction Program.https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program
- Naylor, M. D., et al. (2017). Transitional Care Model: Translating Research Into Practice. https://www.nursing.upenn.edu/ncth/transitional-care-model/
- American Organization for Nursing Leadership (AONL). (2022). Nurse Executive Competencies.https://www.aonl.org/resources/nurse-leader-competencies
- Agency for Healthcare Research and Quality (AHRQ). (2020). Care Coordination Interventions.https://www.ahrq.gov/ncepcr/care/coordination.html
FAQs
What is the purpose of a Transitional Care Program?
It maintains continuity of care following discharge and reduces readmissions through follow-up, education, and coordination by nurses.
How do nurse leaders shape the future of healthcare?
They exercise strategic leadership, guide change efforts, and facilitate interprofessional collaboration to address healthcare problems.
Why prioritize hospital readmissions?
High readmission rates are a sign of inadequate transitions of care and lead to financial penalties and lower quality scores.
