Implementation of a Transitional Model of Care for Congestive Heart Failure

Implementation of a Transitional Model of Care for Congestive Heart Failure

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During exacerbations of Congestive Heart Failure (CHF), older patients may receive care in multiple settings; often resulting in fragmented care and poorly-executed care transitions. The negative consequences of fragmented care lead to duplication of services; inappropriate or conflicting discharge instructions, medication errors, patient/caregiver anxiety, and increased costs of care. In light of changes in Medicare reimbursement penalizing hospitals with above set limits for heart failure (HF) readmissions, models of care are being evaluated for their effectiveness in satisfying this change as well as reducing fragmented care in this population. This paper reviews the Transitional Care Model created by Dr. Mary Naylor at the University of Pennsylvania (Penn Nursing Science, 2013). This model in introduces a patient-centered interdisciplinary team intervention designed to improve transitions across care settings.

Congestive Heart Failure
Congestive heart failure (CHF) is a condition in which the heart is incapable of adequately pumping blood throughout the body or unable to stop blood from backing up into the lungs. The most common cause of CHF is hypertension, previous myocardial infarctions, disorders of the heart muscle or the valves of the heart, and chronic lung diseases such as asthma or emphysema. CHF is a common diagnosis for individuals sixty five years and older. With the growing population of baby boomers, the rate of CHF is predicted to nearly double over the next forty years and will be a drain on healthcare resources. Treatment costs are estimated around $20 to $40 billon, with $8 to $15 billion spent on hospitalization alone (Quaglietti, Edwin, Ackerman, & Froelihe...


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...he Medicare Fee for Service Program. New England Journal of Medicine, 360: 1418-1468.
Naylor, M. (2012). Transitional Care Model. Retrieved from http://www.fiercehealthcare.com/special-reports/transitional-care-model
Penn Nursing Science. (2013). Transitional Care Model-About TCM. Retrieved from http://www.transitonalcare.info/about.tcm
Quaglietti, S. E., Edwin, J., Ackerman, L., & Froeliher, V. (2000, November/December). Management of the Patient with Congestive Heart Failure Using Outpatient, Home and Palliative Care. Progress in Cardiovascular Diseases, 43(3), 259-274. Retrieved from www.cardiology.org/recentpapers/susiechf:pdf
Senthilraj, G., & Ganeshan, R. (2013). Effects of a Hospital Wide Quality Improvement (Doctoral dissertation, University of Connecticut). Retrieved from http://digitalcommons.uconn.edu/cgi/vecontent.cgi?article=1464&context=gs_thesis

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