Patient care models

Patient care models used in the organization where you are employed:

As a home health nurse one of the models we use is the transitional care model (TCM).  The TCM was designed to assist patients transition from an acute care setting (like a hospital) to their home or other care setting.  It prepares patients and family caregivers to more effectively manage changes in health associated with multiple chronic illness.

•            What works well in the model? 

The TCM helps to avoid hospital readmissions for primary and complicating conditions. It also has shown to improve health outcomes for patients after their initial hospital discharge.  Caregivers and patients also feel an enhancement of their care, they feel better educated and prepared for complications. 

•          What doesn't work so well?

Often times patients feel a greater concern about when a patient does need to be readmitted.  I believe the patients feel as though they have done something wrong.