Change Proposal: Transition of Care Model

Change Proposal: Transition of Care Model

Change Proposal: Transition Care Model

In the contemporary medical world, a high hospital readmission rate of diseases is unthinkable given its association with low quality of care. Moreover, its ramifications are enormous and harsh to bear. For instance, in the USA, high hospital readmission rates would result in financial penalties by Centers for Medicaid and Medicare Services (CMS) as a means to inculcate high standards of care in these institutions (Consumer Reports, 2014). As such, there is a need to institute measures that will facilitate the reduction of incidences of hospital readmission of all age groups but with a special focus on the most vulnerable populations like the young children and elderly persons. In essence, this paper aims at establishing the efficacy of a Transition Care Model (TCM) as a change proposal compared to the communication handover technique, SBAR (Situation, Background, Assessment, and Recommendation) in reducing readmission of a high-risk population, elderly patients aged 55 years and above.


Over the recent years, the transition of care practices across various settings has significantly changed, and currently, they constitute several models. According to the Joint Commission, (2012) transition of care refers to all set of activities that ensures the continuity when patients move from one setting to another or within different care levels. Commonly used care transition models include but not limited to Transition Care Model (TCM) and communication handover technique, SBAR. Without a doubt, both models have significantly improved the continuity of care as evidenced by reduced instances of communication breakdown and improved patient outcomes such as decreased incidence of hospital readmissions. However, more contribution of this kind is an expectation that most healthcare stakeholders would wish for all age groups. That is the case given the high incidence of hospital readmissions among the elderly persons after 30 days of discharge.

Problem statement

According to the Consumer Reports, (2014), approximately one in every seven patients, who have undergone extensive surgery, is readmitted in less than 30 days after discharge in the USA. Moreover, across the 50 states, close to 28% of hospital readmission rates were high and cost Medicare almost $17.5 billion dollars yearly. The statistics were mainly for patients aged 65years and older taken in the period between July 2011 to June 2012. Evidently, the figures are worrying and necessitate quick address. Also, since the elderly persons constitute the vulnerable population that requires extra and special attention, such a statistic further sparks a need for change.

Purpose of the Change Proposal

Of utmost importance to this change, proposal is the establishment of the efficacy of a Transition Care Model (TCM) in reducing hospital readmission of a high-risk population, elderly patients aged 55 years and above.

PICOT Question

Central to the achievement of the purpose of this study is the PICOT question highlighted below:

In patients age 55 years old and greater (P), does the use of transition care model programs such as The Transitional Care Model or Project BOOST (I) compared to handover communication techniques such as SBAR(C) reduce the rate of hospital readmissions (O) when transferring patients from one setting to another within 30 days (T)?

Literature Search Strategy

At the heart of the employed search strategy were two online databases, namely, PubMed, which was the primary source of studies and CINACHL. In both databases, the PICOT question offered the search keywords used in the determination of the studies focusing on determining the effectiveness of Transition Care Model in the reduction of hospital readmission among the elderly persons. In the pursuit of supporting evidence in the PubMed database, the Medical subject heading (MeSH) terms included Transition Care Model, hospital readmission, and elderly population. On the other contrary, in the CINACHL search, the general terms utilized were Transition Care Model, hospital readmission, and elderly population. Finally, for the enhancement of validity and relevance, the search used filters such as studies conducted between 2012 and 2017 and the English language. 17 out of the possible 33 studies that met the criteria were reviewed. Details of the search strategy are as depicted in appendix 2.

Evaluation of the literature

Seven of the total studies included for the review looked into the communication handover techniques commonly utilized in the health care setting. A characteristic observation noted in most of these studies was the significant gaps in quality, equity, efficiency and effectiveness in symptoms management that communication handover techniques especially the SBAR possessed (Adams et al., 2012; Bruton et al., 2016; Drach-Zahavy et al., 2014; Holly & Poletick, 2013; Kear, 2016; Lee et al., 2015; Spooner et al., 2016).

On the contrary, ten studies explored the Transition Care Model, which entailed various interventions such as the discharge teach-back method, follow-up visits, making telephone calls to contact patients after discharge and collaborating with community organizations to promote the continuity of care. Besides, all these studies highlighted that transition care interventions resulted in a reduction of the hospital readmissions and improved the patients’ outcomes (Andrew et al., 2016; Bleijenberg et al., 2013; Crist et al., 2017; Hirschman et al., 2015; Hudson et al., 2014; Hung & Leidig, 2015; Melby et al., 2015; Rantz et al., 2015; Toles et al., 2012; Uhrenfeldt et al., 2013).

A common limitation noted across the reviewed literature is that the sample sizes utilized were small and thus generalization of the study findings is not practical (Bleijenberg et al., 2013; Bruton et al., 2016, Crist et al., 2017, Drach-Zahavy et al., 2014; Lee et al., 2015; Toles, et al., 2012). Another weakness noted in the reviewed studies is that they mostly focused on a single setting instead of multiple settings for the ascertainment of the efficacy of the interventions.

Applicable Change or Nursing Theory utilized

The theoretical framework that steers this proposal is the theory of the transition experience. As reported by Shields, (2012), the theory of transitions originates from the likely problems that people are likely to experience because of inadequate preparation to transitional experience (role insufficiency), as well as the change of both preventative and therapeutic action (role supplementation). Nurses are part of the transitional experience if it involves health issues, wellbeing and self-care ability. Central to this proposal is the health transition particularly of elderly patients from healthcare setting to home environment.

Proposed Implementation Plan with Outcome Measures

Of the essence to the implementation of the Transition Care Model is a Master’s prepared advanced practice registered nurse (APRN) who has undertaken a live webinar course for four weeks before taking responsibility of care for older adults (Hirschman et al., 2015). Only after this preparation is when an APRN can take charge of the implementation process. Activities conducted by the APRN include periodic home visits and/or scheduled phone calls. The estimated timeframe is 4 weeks, and the approximate budget for the full plan implementation is $ 460 going by the valuations of preceding projects.

Potential Barriers to Plan Implementation and Ways to overcome them

Implementation of this proposal will not be devoid of its challenges. A case in point of such problems is language barrier. Since most of the program targets the elderly population, language is a possible barrier especially for non-English speaking individuals who are not able to understand the language preferred by the providers of care. Another obstacle to the implementation of the change proposal is inadequate organizational support. That is the case because organizations may be unwilling to spend more resources in the care of a discharged patient (Hirschman et al., 2015).

Given the cited challenges, solutions to these problems are of the essence since without such the implementation is likely to fail. Primarily, the healthcare professional can address the issue of language barrier through seeking the services of a family member to assist in the translation of the instructions to the elderly persons. As for the challenge of limited organizational support, a nurse should gear more efforts towards soliciting support from the organization so that they can have the surety of the implementation not failing in the end (Hirschman et al., 2015).


In closure, this paper aimed at determining the efficacy of the Transition Care Model as a change proposal compared to the communication handover techniques like SBAR in reducing hospital readmissions of the elderly aged 55years and above. From this analysis, it is beyond doubt that the Transition Care Model utilization in other places has indicated a reduction in the overall hospital readmission rates. As such, its implementation in the other areas is of the essence for the achievement of the same outcomes. Failure to do so, however, will result in persistence of poor health indicators such as high readmission rates to the unforeseeable future.


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Bleijenberg, N., Ten Dam, V. H., Steunenberg, B., Drubbel, I., Numans, M. E., Wit, N. J., &

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Rantz, M. J., Flesner, M. K., Franklin, J., Galambos, C., Pudlowski, J., Pritchett, A., Alexander, G., & Lueckenotte. (2015). Better care, better quality: reducing avoidable hospitalizations of nursing home residents. Journal of Nursing Care Quality. 30(4), 290-297.Retrieved from

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Spooner, A.J., Aitken, L.M., Corley, A., Fraser, J.F. & Chaboyer, W. (2016). Nursing team leader handover in the intensive care unit contains diverse and inconsistent content: an observational study. International Journal of Nursing Studies, 61, 165-172. Retrieved from

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Appendix Section

Appendix 1 Theory of Transition


Appendix 2: Search Strategy Results

Database searched Search terms



Years searched Number of articles identified Number of articles included Number of articles excluded
PubMed MeSH:

·         “Transition Care Model”

·          “hospital readmission”

·         “elderly population”

·         2012-2017


·         18


·         9 ·         9
CINACHL General:

·         “Transition Care Model”

·          “hospital readmission”

·         “elderly population”

·         2012-2017 ·         15


·         6 ·         9