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Care Transitions Models for Chronic Disease Management

Care transitions models can help patients with chronic diseases who are transitioning between healthcare settings. The Centers for Medicare & Medicaid Services (CMS) defines a transition of care as the movement of a patient from one setting of care to another. Settings may include rehabilitation facilities, home health, long-term care facilities, primary care practices, specialty care practices, and hospitals.

When patients transition between healthcare settings it can cause a gap in care, especially among adults with multiple chronic conditions (MCCs). As a result, patients with MCCs moving between healthcare settings often experience high rates of preventable emergency department visits and hospitalization. Care transitions strategies can support patients by providing monitoring, management, and continuity of care. To learn more about care transitions in rural communities, see Rural Post-Acute Care: Improving Transitions to Enhance Patient Recovery.

The main goal of all care transitions models is to build a personalized patient care plan that addresses the patients' needs while providing a continuum of care. Three models that are commonly implemented in rural communities are:

Transitional Care Model (TCM)

The Transitional Care Model (TCM) is a nurse-led intervention that focuses on assisting older adults at risk for poor health outcomes as they move across healthcare settings or between clinicians. TCM focuses on decreasing hospitalizations and readmissions for vulnerable patients. TCM prepares patients and caregivers to manage changes in health associated with MCCs. TCM has nine key components that help create a successful transition:

  • Screening
  • Staffing
  • Maintaining
  • Engaging
  • Assessing
  • Educating
  • Collaborating
  • Promoting continuity
  • Fostering coordination

Community-Based Transition Model (CBTM)

The Community-Based Transition Model (CBTM) was developed by home care providers with the goal of equipping clinicians with skills to address gaps in all care transitions. CBTM focuses on delivering patient-centered chronic care management by addressing patients' goals with evidence-based care. CBTM focuses on:

  • Ensuring patients take medications as prescribed
  • Identifying patient-specific concerns to the transition process
  • Using remote patient monitoring to promote behavior changes
  • Supporting health literacy

Coleman Care Transitions Intervention (CTI)

The Coleman Care Transitions Intervention (CTI) is a short-term model that empowers chronically ill adult patients to develop self-care skills and helps them take a more active role in their health. Patients work with a transition coach, who teaches them self-management tools and tools to enhance communication. CTI can be effective in reducing hospital readmissions and improving disease self-management. The four components of CTI include:

  • Understanding of medications and using self-management processes
  • Understanding and using patient-centered records
  • Scheduling and completing primary care and specialist follow-up visits
  • Knowledge of indicators for changing or worsening conditions

Examples of Rural Communities Using Care Transitions Models for Chronic Disease Management

  • Avera Health, located in South Dakota, uses CTI to aid recently discharged, newly diagnosed, or chronically ill cardiac patients with congestive heart failure. Avera Health provides remote patient monitoring technology for patients returning home after a care transition.
  • Genesis HealthCare System's COPD Readmission Prevention Program in Zanesville, Ohio, uses a care management approach to reduce hospital readmission rates for people with COPD. Registered nurses serve as both patient navigators and treatment specialists and offer transitional care services to assist people with COPD. Nurse navigators monitor patients' progress through virtual follow ups and provide timely disease and self-management education. Registered nurses or nurse practitioners provide home visits that allow for frequent assessments and care plan adjustments. This saves the participants travel time to a clinic or emergency room. The program has shown great results with hospital readmission rates decreasing by 34% over six months.
  • Southwestern Vermont Health Care (SVMC) created a Transitional Care Nursing Program, based on TCM, that empowers patients to actively manage their care. SVMC uses a team of experienced nurses to identify people who have a chronic disease and could use assistance with the transition from hospital to home. Nurses help participants develop healthy routines, organize medications, and understand how to ease symptoms.
  • MaineHealth Care at Home (MHCAH) provides a range of home health services. The care team consists of home health aides, specialty-trained nurses, nutritionists, speech language pathologists, social workers, rehabilitation therapists, and occupational therapists. MHCAH is implementing Project COPD, which uses CTI and other evidence-based practices to reduce rates of hospitalization and emergency department visits by improving transitions of care and improving quality of life for people diagnosed with COPD.

Implementation Considerations

Several care transitions models use health coaches to support patients with their care plans. Health coaches help patients make positive lifestyle changes, increase ability to track and monitor chronic health conditions, and slow disease progression.

Challenges with implementing programs using a Care Transition model can occur when transitioning care into the home. Often, patients require additional support when they leave a hospital setting and transition to their home. For example, they may need reminders about the medical guidance received or additional support with modifying behaviors. One approach for supporting patients is to schedule wellness checks or develop follow-up plans. Wellness checks may be an in-home visit by a healthcare professional, a family member, or friend. This helps keep patients accountable and motivated to manage their chronic disease.

Program Clearinghouse Examples

Resources to Learn More

Contextual Frameworks for Research on the Implementation of Complex System Interventions: Care Transitions Framework Chapter
Provides details regarding the characteristics, implementation, and factors associated with the care transitions framework. Tables further describe the intervention characteristics and external context of the framework, and a flowchart offers guidance to demonstrate how they can be used.
Author(s): Rojas Smith, L., Ashok, M., Dy, S.M., Wines, R.C., & Teixeira-Poit, S.
Organization(s): Agency for Healthcare Research and Quality
Date: 3/2014

Continuity of Care: The Transitional Care Model
Summarizes the evidence base for the transitional care model (TCM), identifies the key components necessary to create a TCM, and discusses evaluating the application of the core components and impact of the TCM model.
Author(s): Hirschman, K., Shaid, E., McCauley, K., Pauly, M., & Naylor, M.
Citation: Online Journal of Issues in Nursing, 20(3)
Date: 9/2015

Review of Current Conceptual Models and Frameworks to Guide Transitions of Care in Older Adults, Tables 1 and 2
Table 1 lists six different types of care transitions models with corresponding settings, tools or components, and key findings. Table 2 lists 19 commonalities among the six transitional care models.
Author(s): Enderlin, C.A., Mcleskey, N., Rooker, J.L., et al.
Citation: Geriatric Nursing, 34(1), 47-52
Date: 2013

Transitional Care Nurse Role
Explores the transitional care nurse (TCN) model by describing the key components of a transitional care program and the criteria for admission into transitional care. Defines the role of TCNs and demonstrates the value of a transitional care program in achieving improved outcomes.
Author(s): Richardson, B., & Coppin, K.
Organization(s): American Nurses Association
Date: 6/2021