BOX 2-6

Case Study: The Transitional Care Model

Easing Transitions, Fostering Freedom: The Transitional Care Model “Speaks to What Nurses Really Do”


Mary Manley was accustomed to her independence. Having lived for many years on her own in North Philadelphia, worked until age 74, and cared for her infant great-granddaughter in her early 80s, she was undaunted by a diagnosis of diabetes in late 2007. “I didn’t have to go to doctors too much,” she said. “I was perfectly healthy, doing anything I wanted to do—“until 2009, that is, when ‘the sickness’ came.”

“The sickness” was, in fact, many chronic conditions (among them hypertension, mild cognitive impairment, coronary artery disease, and chronic obstructive pulmonary disease) and two life-threatening acute conditions. The latter conditions—pneumonia and pancolitis, an intestinal inflammation caused by Clostridium difficile, a “superbug” that is often resistant to treatment—required hospitalization.

Ms. Manley received vancomycin intravenously for the C. difficile for two weeks as an inpatient. She was discharged on a Thursday afternoon with a prescription for oral vancomycin that her niece dropped off at a neighborhood pharmacy. But on Friday the pharmacy claimed not to have received the order and refused to dispense the drug.

While hospitalized, Ms. Manley had met a transitional care nurse, Ellen McPartland, MSN, APRN, BC, who made a home visit on Friday. When she heard about the potentially grave delay in antibiotic therapy, she called the pharmacy immediately, demanding to speak with a supervisor. The pharmacy dispensed enough medication to get Ms. Manley through the weekend at home until the full amount could be obtained on Monday—an outcome that prevented immediate rehospitalization and may have saved Ms. Manley’s life.

We have not, as a health care system, figured out how best to respond to the needs of people with multiple chronic conditions. The Transitional Care Model is one approach to change the system to be more responsive to their needs.


—Mary D. Naylor, PhD, RN, FAAN, developer of the TCM

According to a recent study, 20 percent of hospitalized Medicare beneficiaries are readmitted within 30 days of discharge and 34 percent within 90 days, at an estimated cost in 2004 of “$17.4 billion of the $102.6 billion in hospital payments from Medicare” (Jencks et al., 2009). Among innovations aimed at reducing rehospitalization rates, the Transitional Care Model (TCM) relies on an advanced practice registered nurse (APRN), like Ms. McPartland, who meets with the patient and family caregivers during a hospitalization to devise a plan for managing chronic illnesses (see www.transitionalcare.info).



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