One of the primary places along the care continuum providers are looking for both efficiency and savings is in the transition points move from one healthcare setting to the next. Long considered a "gap" in the continuum, those transitions are increasingly being managed by advanced practice nurses (APN) in an emerging position described, not surprisingly, as the "transitionalist."
As a recent article for the Advance Healthcare Network points out, it's widely understood that the U.S. "healthcare delivery system often fails to meet the needs of elderly and chronically ill patients during transitions of care from one setting to another. This problem is multifaceted and can be attributed to fragmented responsibility, lack of care coordination including communication among providers and little to no medical knowledge by the patient and family members or caregivers."
In only the last few years, the article notes, strides have been taken toward creating a position that could "effectively bridge the transitional care gaps, reimburse for these services and hold these practitioners accountable for patient outcomes." The model being developed, known as the "APN Transitional Care Model (TCM)," focuses on identifying patient health goals, ensuring coordination and continuity of care, the development of a streamlined plan of care and active engagement with patients and caregivers in order to implement that plan.
Among the key elements of the TCM are "an APN with advanced knowledge and skills in the care of the particular population as the primary coordinator of care, collaboration of the APN with team members to reduce adverse events and prevent functional decline, development of an evidenced-based plan of care by the APN, and home visits by the APN, with ongoing telephone support, for 2 months post-discharge."
In recognition of the potential of transitional care programs, the ACA established the Community-Based Care Transitions Program, "which provided half a billion dollars from 2011 to 2015 to healthcare systems and other community organizations that provided at least one transitional care intervention to high-risk Medicare beneficiaries." The interventions covered included medication review and management, assessment and active engagement of patients and their family/caregivers through self-management support and home health visits. "CMS also offered an opportunity to identify, evaluate and disseminate innovative care delivery and payment models, including transitional care, through a $10 billion allocation for the period 2011-2019."