Table 2.

Key Components of the Transitional Care Model Intervention Protocol

1. Schedule of Advanced Practice Nurse (APN) visitsa:

Patient–caregiver (CG) dyad visited within 24 hr of study enrollment

At least daily throughout hospitalization

Within 24 hr of skilled nursing facility (SNF) admission or discharge to home

At least weekly during first month postdischarge from hospital to SNF or home

At last semi-monthly throughout the duration of the intervention

2. Hospital component/primary goals:

Establish trusting relationships with patient and CG

Implement targeted risk reduction strategies to prevent/minimize the effects of cognitive impairment

Develop individualized care plans in collaboration with patient, CG, and patient’s health care providers

Begin to implement plans

3. Home Component: begins immediately posthospital discharge to home or SNF.

4. Discharging the patient–CG dyadb:

APNs use clinical judgment to determine length of intervention. Termination guided by:

Patient is medically stable

Patient–CG goals

CG able to identify early symptoms that require intervention and strategies for preventing poor outcomes

^aNote: While the proposed schedule defines minimal expectations, APNs use clinical judgment to determine frequency (number) and intensity (length) of patient–CG visits and telephone contacts.

^bFor a dyad to be considered having “received the intervention” a minimum of four home visits (SNF and/or home) must have occurred.