Transitional Care Model: A New Community Care Management Model
DOI:
https://doi.org/10.26512/gs.v11i1.28404Keywords:
Transitional Care Model; Community Nursing; ElderlyAbstract
As hospital admissions have increased, the readmission rate has increased by approximately 8%. It is essential to adopt measures aimed at reducing these values ”‹”‹and consolidating an effective transition between primary and hospital care. This article aims to demonstrate a tool to reduce hospitalizations of patients with frailty in the home context, using the Transitional Care Model (TCM). The work is quantitative, descriptive and exploratory, according to the method of health planning process, application at home of the Edmonton Frail Scale, Morse Falls Scale and application of sociodemographic questionnaire. The sample is 37 users, 78.4% of women retired, 67.6% of lower class, 91.8% had at least one visit to the emergency room service, 97.3% of medium and high use. 63% risk with moderate to severe frailty. In spite of high frailty of the elderly at home, an application of this model that reduces the barriers between levels of care, with health gains as well as economic effectiveness by reducing the number of days of hospitalization. This will prevent complications and improve chronic disease management through the application of a new care management model.
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