¶ … 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.

Development team for innovative nursing care model

The Model also addresses the need for effective home health care. For patients with chronic health conditions, having trained staff attend to the patients both in the hospital and at home are vital for a seamless transition from one environment to another. A team of nurses...

"This model is designed to help patients more effectively manage significant transitions in their care, primarily from the hospital to home or from the hospital to a skilled nursing facility to home" (Care Transitions Intervention, 2013, Innovative Care Models). Thus, the team must include nurses at the hospital who can orient caregivers and patients in the life skills needed to manage chronic conditions.
However, professional assistance from nurses to the patient's home is likely to be required on a regular basis, given the severity of the medical complaints the model is intended to treat. Typical conditions include "post-discharge SNF or home health care or intensive anticoagulation management" such as "congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease" (Care Transitions Intervention, 2013, Innovative Care Models). Patients under care via the model also may suffer from "diabetes, stroke, medical and surgical back conditions (predominantly spinal stenosis), hip fracture" and run the risk of "peripheral vascular disease, cardiac arrhythmias, deep venous thrombosis, and pulmonary embolism" (Care Transitions Intervention, 2013, Innovative Care Models). Home caregivers must understand the appropriate precautions to take and must be supported by trained visiting nurse staff that regularly check patient vital signs and give support.

Incorporation of selected model into my work setting

Training is required for all staff to understand the worldview…