Transitional Care Model Evaluation 2020

The Transitional Care Model (TCM) is an advanced practice registered nurse (APRN) led, team-based, care management strategy designed to improve the care and outcomes of high-risk older adults transitioning from hospital to home. Eligible patients who agree to participate in the study will be randomly assigned to either the intervention group, which receives the TCM intervention, or the control group, which receives usual care (standard hospital discharge planning and post-hospital follow up services). The target sample size for the study is close to 1000, evenly divided into intervention and control groups, with 250 to 270 patients derived from each of UCSF and Trinity health systems, and another 450 recruited from the two VHA hospitals combined. Data will be collected at intake, prior to randomization, by enrollment coordinators at each of the participating hospitals. Followup data will be collected in a survey of patients conducted 90 days after discharge, and from claims data obtained from Medicare, Medicare Advantage plans, and the VHA.

Inclusion criteria

• Age 65 years and older
• Admitted from home with Pneumonia OR with a history of HF or COPD with symptoms of HF or COPD exacerbation or whose symptoms suggest a new HF or COPD diagnosis
• English and non-English speaking, able to respond to questions
• Reachable by telephone after discharge
• Resides within the geographic service area
• Consent to participation

Exclusion criteria

• Enrolled in Medicare's Hospice or End-Stage Renal Disease programs
• Presence of active and untreated psychiatric conditions (ICD10: F10-F29)
• Long-term care resident
• Undergoing active cancer treatment
• Currently enrolled in another RCT