The Transitional Care Model is a philosophy that focuses on the roles of transitional care nurses and nurse scientists in improving patient quality of life.

Nursing's New Mission: Transitional Care Nurses Work to Improve Quality of Care

A quiet revolution in quality health care, dubbed the "Transitional Care Model," or TCM, is profoundly shaping the delivery and future of health care. The National Institute of Nursing Research may not yet be widely known, it is the leader in this philosophy that's been gaining momentum over the last 25 years.

NINR is one of 27 institutes and centers within the National Institutes of Health, all of which are devoted to the improvement of national health. NINR's approach, however, is a bit different.

"We focus primarily on funding clinical research that crosses a spectrum of diseases," says Patricia A. Grady, RN, PhD, and director of NINR. "Our investigators study disease prevention, symptom management and end-of-life and palliative care."


Focus on 'hand-off' of care

NINR-funded research studies closely evaluate how to improve health outcomes while increasing the quality of care received in various settings, from in-hospital stays to at-home recoveries. A growing body of evidence indicates that one-third of older adults and caregivers had poor satisfaction relating to care and unmet needs, particularly during the "hand-off" from hospital to home. TCM was conceptualized to prevent this breakdown in care.

TCM is premised on comprehensive in-hospital planning coupled with home follow-up for chronically ill, high-risk older adults hospitalized for common surgical and medical conditions. The founding principles of TCM are continuity and individualized care, prevention and avoidance of complications, and closely-followed clinical treatment and management. In essence, a collaboration is formed between patient, family and medical team including the patient's physicians, nurses, home care aides and caregivers.

"Nursing science focuses on improving health outcomes and quality-of-life for individuals, families and communities in real world settings," Grady says. "Our research encompasses every discipline and every stage of life--from genomic research in the laboratory, to family health practice in the community, to health policy formation in the legislature."


Nurses play key role in transitional care

At the heart of the TCM model is the Transitional Care Nurse, or TCN. This TCN role is aptly described by Maya Angelou's quote, "They may forget your name, but they will never forget how you made them feel."

The TCN follows each participating patient from the hospital to his or her home, using an evidence-backed coordination of care plan designed to increase care quality, prevent potential decline and avoid re-hospitalization. This specialized nurse collaborates with other nurses, physicians, social workers, discharge planners, pharmacists, home care aides, and other members of the patient's health care team, all of whom are focused on increasing a patient's care and quality of life.

As quality of life and disease prevention philosophies gain momentum, Grady firmly believes the NINR is poised to make an even larger impact in the future.

"It is really exciting right now because there has never been such a need for nurses and nursing research," Grady stipulates. "As people develop chronic illnesses and continue to live longer, there is so much potential to improve the quality of life with the aging population. People are more savvy now about prevention and want to take care of themselves and be healthy, so we have an audience that is receptive to what we are trying to say."

In its 25th year, the NINR is focusing efforts on end-of-life and palliative care, foreseeing the needs of an aging population with multiple symptoms and complex diseases. Consequently, the Office of Research and End-of-Life Science and Palliative Care, Investigator Training, and Education, or OEPC, was created. The office's main mission is to identify research projects along these lines, spreading the word that this type of work is needed. It also demonstrates the importance of nurse scientists and how they will contribute and shape the future of health care.


The future

Mary E. Kerr, RN, Ph.D., and deputy director of the NINR, encourages nurses to consider research professions because they may already have the skills critical to research investigators.

"Nurses are already trained to make clinical observations and to evaluate patients, and this is the basis for research," Kerr explains. "Some researchers who have never seen a patient are interested in the science but not the applications. Nurse scientists want to improve outcomes and help patients, and they can do that through research."

Even after celebrating its silver anniversary, NINR is just getting started, pioneering initiatives for better care amid an aging population. The landscape of quality and cohesive health care is a dynamic environment, and transitional care nurses and nurse scientists are at the forefront.

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