The Care Transitions Intervention Model in nursing practice

¶ … Innovative Nursing Care Delivery Models a.This website detailed profiles 24 successful innovative nursing care delivery models. These profiles developed part a research project conducted Health Workforce Solutions LLC (HWS) funded Robert Wood Johnson Foundation (RWJF).

Innovative nursing care model: The Care Transitions Intervention

Innovative nursing care model

I chose the Care Transitions Intervention Model on which to focus because of the increasing importance of geriatric care in the field of nursing. Although my organization serves the needs of persons of all ages, elderly patients are an increasingly large proportion of the patient base. The Model stresses the need for the empowerment and self-care even of patients with high-risk conditions. The Care Transitions Intervention Model allows elderly patients the maximum amount of mobility and autonomy possible given the limits of the patient's condition and enables them to stay in a home setting as long as possible. As its name suggests, the model facilitates the transition of the older patient from an acute care setting to a home care setting. As well as being less stressful for the patient, a home-based care setting is also more cost-effective and an increasing necessity within many resource-strapped healthcare organizations.

Incorporation of selected model into my work setting

Training is required for all staff to understand the worldview conveyed by the model: it is not enough merely to care for patients, it is also important to create a bridge between hospital and home, which means involving all members of the patient's family. An initial orientation in the model is required, specifically designed to prepare staff to convey medical knowledge to laypersons.

Change is always difficult for any organization, but for a healthcare organization it can be particularly entrenched. Often, the focus is simply upon dispensing care rather than teaching others how to give care. Unfortunately, the result of this gap between the ability to convey understanding and knowledge can leave caregivers under-informed. The organizational model of change integration is one in which participants must be convinced of the need for and the value of the change (the unfreezing process); the change process itself; followed by the refreezing process whereby the change become a standard operating procedure of the organization (Kurt Lewin Change Model, 2013, Change Management Coach). In this instance, gaining buy-in from the nurses who will be providing the care to the patients in the program and orienting the caregivers is essential, since they are on the front lines of the provision of this intensive, home-based treatment. "The key to the problem is to understand the true nature of resistance. Actually, what employees resist is usually not technical change but social change -- the change in their human relationships that generally accompanies technical change" (Lawrence 2013). Visiting nurses who provide routine home visits must also understand their roles: although they may be called upon to perform certain duties which only medical personnel can provide, whenever possible they should also be aware of the need to show caregivers how to take on the responsibilities so that the patient has consistent medication, monitoring, and his or her life needs taken care of daily.

A final component of the program is ensuring that appropriate measures can be taken if anything goes wrong. One of the requirements of participation for patients is a working phone, to ensure that if the patient's health becomes unstable, the hospital staff can be immediately notified (Care Transitions Intervention, 2013, Innovative Care Models).

Implementation and evaluation

Participants may be asked to regularly evaluate their participation in the program on a satisfaction scale. Nurses participating in both the hospital and home-based components of the process will be interviewed after the trial phase to provide advice about any needed reforms or restructuring. Finally, the vital signs of all patients will be monitored and mortality outcomes will be evaluated and compared against control group of demographically similar patients which did not receive the intervention.