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- Volume 1(Issue 1) JANUARY- JUNE 2025
Research Articles
The Transitional Care Model Focuses on Managing The Hospital At Home
Vol.1(1); Pages:1-9. Published on May-2025
Abstract
The Transitional Care Model (TCM) serves as a patient-focused healthcare system that focuses on improving hospital-to-home transfers of care mainly for people using hospital-at-home services. A healthcare model was created to address patient challenges during healthcare transfers between environments by focusing on quality care delivery in home settings. Hospital patients typically experience major disruptions when care stages change between different service locations which produces patient accidents and readmissions while causing treatmentrelated stress. The TCM develops a controlled and coordinated patient transfer between hospital and home care to enhance treatment results and decrease healthcare expenses and psychological strain affecting both patients and healthcare institutions. The TCM holds an essential role in adding value to hospital-at-home services because healthcare needs from aging populations continue developing thus supporting better quality care with efficiency and cost-effectiveness for home-based patients. Hospital-at-home management benefits from the Transitional Care Model which provides total support to ensure patients acquire needed resources toward home recovery success. The TCM successfully remedies hospital readmission issues and enhances patient results by maintaining health service alignment and building strong patient-provider connections. This model both caters to patient needs and benefits from healthcare professional support and technological systems to change how healthcare provision functions especially for people selecting hospital-at-home delivery.
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An Integrative Review of Hospital-to-Home Care Transitions
Vol.1(1); Pages:10-17. Published on May-2025
Abstract
The phase between hospital and home care creates a high-risk scenario where patients become more vulnerable to undesirable incidents while showing increased risk of medication misalignment and avoidable hospital returns. The foundation of safe patient-centered care treatment throughout transitions depends on home health nursing. Health services at home have become vital because of growing hospital stay expectations alongside treatment needs for patients with long-term conditions. The research evaluates evidence-based practices across the healthcare delivery field together with its existing barriers and upcoming opportunities. Home health services developed into crucial bridging services because hospital stays decreased while chronic illnesses increased. Home health nurses remind patients about medications and teach families how to care for the patient while also detecting medical declines early in patients’ homes. Clinical research shows that transitional care systems led by nurses who use the Transitional Care Model (TCM) and Care Transitions Intervention (CTI) lead to fewer 30-day hospital returns as well as higher patient ratings and cost savings in healthcare. Home health nursing delivers many advantages to healthcare patients through several nursing barriers stemming from unclear hospital-home provider relations and inadequate payments for transition services coupled with small staffing numbers across settings. The paper advocates for three policy recommendations which involve strengthening care coordination structures and expanding transitional care payment systems and creating programs to ready nursing staff members for home-based transitional practices. Future studies must evaluate the results of culturally respectful care approaches with specific interventions for vulnerable patients next to assessments of digital health platforms used in patient transition care. Home health and transitional nursing consist of vital elements which guide patients through hospital treatments into successful recovery at their homes. The paper demonstrates the necessity for permanent funding and research programs and policy endorsements to establish effective care for diverse patient groups throughout their transitional phase.
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Development of a Home Health Transitional Care
Vol.1(1); Pages:18-24. Published on May-2025
Abstract
Patient vulnerability during hospital-to-home transitions becomes most evident when patients manage chronic conditions while using complicated medication treatments and lack sufficient family support. When patients lack proper follow-up care and coordinated medical treatment their risks increase for negative medical outcomes and emergency hospital returns and overall reduced life quality. Home health nurses can successfully close this care space however standard evidence-based transitional strategies which link hospital discharge to community care require further advancement. A detailed process of creating the Home Health Transitional Care Model (HHTCM) has been launched because it promises to advance care quality and patient healthcare results while reducing the number of readmissions after discharge from hospitals. Nurse-led interventions combined with individualized care plans and educational support and regular follow-up operations form the core of this model to achieve safe recovery at home. A systematic review of recent research about transitional care along with home health practices and hospital discharge management used PubMed and CINAHL along with Scopus databases. The HHTCM developed through a synthesis process which integrated major themes alongside evidence-based practices. Two groups of stakeholders including hospital discharge planners and home health nurses and patient representatives provided input to validate the model’s practical utility. The model components received TCM framework alignment as an integration format for use in existing home health nursing practice frameworks. The Home Health Transitional Care Model functions using five essential components. The model’s core components consist of (1) Pre-discharge assessment with care planning and (2) Immediate post-discharge home health visits within 24-48 hours and (3) medication review followed by patient education and (4) definitive symptom management with telephonic assistance and (5) continuous communication with primary care and specialty providers. Throughout patient care delivery nurses fulfill multiple functions as care coordination specialists and education providers and advocates for patient rights. Across healthcare settings the adoption of telehealth with electronic health records technology improves both communication processes and documentation practices. Initial implementation of the HHTCM in a testing home health agency produced significant benefits such as decreased 30-day readmissions by 25% while simultaneously improving patient satisfaction scores along with the quality of nurse-provider interactions. Patients gained confidence in self-care while home health nurses demonstrated enhanced role clarity during patient transitions because of the established Home Health Transitional Care Model. The HHTCM provides a flexible solution for enhancing transitional care results by creating established roles combined with strengthened coordination between providers and early treatment intervention systems. Additional studies need to confirm how this model functions in multiple healthcare settings along with various patient communities.
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The Impact of Nurse-Led Transitional Care Programs on Patient Satisfaction
Vol.1(1); Pages:25-34. Published on May-2025
Abstract
Transitional care refers to a set of coordinated services that support patients as they move from one healthcare setting to another or return home following hospitalization. With growing concerns about hospital readmission rates, medication errors, and gaps in follow-up care, nurse-led transitional care programs (TCPs) have emerged as effective interventions to enhance continuity of care and patient satisfaction. Patient satisfaction, a crucial indicator of healthcare quality, is significantly influenced by communication, understanding of care plans, and perceived emotional and physical support during care transitions. This paper aims to explore and evaluate the impact of nurse-led transitional care programs on patient satisfaction, drawing from recent studies, case analyses, and healthcare system evaluations.Nurses, given their holistic training and patient-centered approach, are uniquely positioned to guide patients through vulnerable periods of transition. Nurse-led TCPs typically include components such as structured discharge planning, post-discharge follow-up (via home visits or telephone), medication reconciliation, patient and caregiver education, and coordination with primary care and specialty providers. These interventions are designed to minimize confusion, ensure treatment adherence, and empower patients with knowledge about their health conditions. Evidence from various clinical trials and observational studies indicates that patients enrolled in nurse-led TCPs report higher levels of satisfaction compared to those receiving standard transitional care. Enhanced communication and education by nurses help patients better understand their diagnoses, treatment regimens, and follow-up schedules. Moreover, patients consistently report feeling more supported, heard, and confident when nurses actively engage them in care planning and decision-making. Key elements that contribute to increased satisfaction include personalized care, timely access to information, and the perceived availability of the nurse as a reliable resource. Furthermore, nurse-led programs have demonstrated effectiveness across diverse populations, including older adults, patients with chronic illnesses such as heart failure or diabetes, and those from socioeconomically disadvantaged backgrounds. In these groups, patient satisfaction is closely tied to health literacy, emotional support, and culturally competent communication—all areas where nurse-led models excel. The nurse’s ability to assess and respond to individual needs, including psychosocial and environmental factors, leads to more responsive and patient-centered transitional care. The implications of this review are significant for healthcare administrators and policymakers. Investing in nurse-led TCPs not only improves patient satisfaction but also contributes to reduced hospital readmissions, better health outcomes, and lower healthcare costs. Future research should focus on the standardization of TCP protocols, integration of digital health tools, and strategies for scaling nurse-led models within community and home health settings. nurse-led transitional care programs play a pivotal role in enhancing patient satisfaction during the critical period following hospital discharge. Their comprehensive, empathetic, and coordinated approach addresses both clinical and emotional needs, making them a valuable component of high-quality, patient-centered care.
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Primary Health Care and the Health for All Movement
Vol.1(1); Pages:35-42. Published on May-2025
Abstract
The movement of elderly patients from hospital environment to home care is a significant and crucial stage in the process of care delivery and this acknowledge due to the rising aging population as well as the complexity of the comorbid conditions they present. This process may require data sharing and communication between the different specialties to guarantee the patient receives the proper care, is not readmitted and has a good quality of life in their older age. Nevertheless, it is still crucial to consider the views of those who are most involved in designing and carrying out transitional care: clinicians. This paper aims to uncover various factors that include perceptions, experiences, and barriers that healthcare professions encounter while discharging elderly patients from the hospital to their homes. As a qualitative research approach, semi-structured interviews were carried out on a purposive sample of nine healthcare providers, including physicians, registered nurses, case managers, and social workers, drawn from hospitals and community care organizations. In order to determine the patterns within the data, thematic analysis approach was used to analyze the data and come up with pertinent themes. Several important aspects were identified and deemed to be key elements when facilitating the continuity of care from the hospital to the community: they included; Teamwork, Patient-Centeredness, Resources within the community, and Organizational support. One of the common issues found was the lack of early and structured communication between the hospitals and primary care physicians. Some of the various common challenges mentioned by participants include lack of proper care coordination, time constrains and poor access to follow up services which influenced patients’ result. Further, regarding care giver readiness, they said that creating awareness as well as educating the care givers of the patients would ensure compliance to set treatment plans and taking of prescribed medication on discharge. Another emerging issue that was identified was that there was lack of protocol and suboptimal interconnectivity of discharge communication between the hospital and home care services. This disrupt is primarily brought about by inadequate follow-ups and eventually leads to high readmissions. Providers called for improved transition models of care, telehealth and more targeted post-acute care case management for geriatrics. However, most of the respondents recognized the value of creating multidisciplinary teams and the patient centeredness in care transitions. House calls, telemedicine support, customized care plans were perceived as beneficial in improving patients’ safety and managing the load within the healthcare system. This present work therefore emphasizes the importance of engaging the healthcare providers in the development and implementation of transitional care models. Delivery of comprehensive care across the hospital-to-home transition of older patients involves addressing systemic voids, fostering interdisciplinary communication, and implementing various forms of support for both the elder patients and healthcare providers. Future policies should focus on transition to coherent and coordinated models of care delivery taking into context the experiences and struggles of personnel on the ground.
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