NUR 650 Module 4 Model Comparison Paper Example

Choosing a Transitional Care Model: Naylor, Coleman and Project RED Compared Against Local Readmission Causes

[Student Name]

Southern New Hampshire University

NUR 650: Care Coordination and Outcomes Management

Module Four Model Comparison Paper

[Instructor Name]

[Date]

Choosing a Transitional Care Model: Naylor, Coleman and Project RED Compared Against Local Readmission Causes

Several transitional care models have been tested in randomized trials and shown to reduce readmissions. Their existence can tempt hospitals to adopt whichever model is best known. Yet models differ in who they serve, what they do and what they cost, and a model that worked in one population may not address the causes of readmission in another. The Module Three analysis at Brookhaven, a composite regional hospital, found that four related causes accounted for most heart failure readmissions: no clinician contact before day seven, patients not understanding or following their diuretic plan, daily weights skipped or ignored and medication cost or access. This paper compares three well-studied models against those causes and argues that a tiered combination of their components, delivered with fidelity to the elements that made each effective, fits Brookhaven better than any single model.

The Naylor Transitional Care Model

Naylor et al. (2004) randomized 239 adults aged 65 and older hospitalized with heart failure to usual care or a three-month intervention led by advanced practice nurses. The nurses began in the hospital with a comprehensive assessment and discharge plan developed with the patient and caregiver, then made home visits and were available by telephone seven days a week, coordinating with the patient's physicians and focusing on symptom recognition, medications, diet and caregiver support. Over one year, the intervention group had a longer time to first readmission or death, fewer readmissions and lower total costs than the control group. The model is intensive, requiring advanced practice nurses with manageable caseloads, and it was tested in older adults with heart failure, a close match to Brookhaven's population.

The Care Transitions Intervention

Coleman et al. (2006) randomized 750 older adults in an integrated delivery system to usual care or a four-week intervention in which a transition coach, often an advanced practice nurse, met the patient in the hospital, made one home visit and followed with three phone calls. The coach did not provide direct care but built the patient's skills in four areas: managing medications, keeping a personal health record, obtaining timely follow-up and recognizing red flags that should prompt action. Readmission rates were lower in the intervention group at 30 and 90 days. The model is less intensive than Naylor's and focuses on patient activation, which directly targets the self-management causes found at Brookhaven. It was tested across several conditions rather than heart failure alone.

Project RED

Jack et al. (2009) randomized 749 adult general medical patients at an urban safety-net hospital to usual care or a reengineered discharge. A nurse discharge advocate arranged follow-up appointments before discharge, confirmed the medication plan, taught the patient with teach-back and provided an individualized after-hospital care plan, and a pharmacist called the patient two to four days after discharge to review medications. The intervention group had about 30% fewer combined emergency department visits and readmissions within 30 days. Project RED standardizes the discharge process itself and is relatively inexpensive, but its post-discharge contact is limited to a single pharmacist call, and it was tested in a younger, urban population.

Comparing the Models

Table 1 shows that each model addresses part of the problem. Project RED fixes the discharge process, including booking appointments and teaching with teach-back, at low cost for every patient. The Care Transitions Intervention builds the self-management skills behind diuretic and weight monitoring failures. The Naylor model addresses all four causes and was tested in the closest population but is the most expensive and would reach only a fraction of Brookhaven's 400 annual heart failure discharges with current staffing.

Table 1. Comparison of Three Transitional Care Models

Note. Each model addresses some of Brookhaven's causes; none addresses all four at a cost the hospital can apply to every patient.

Recommendation: A Tiered Hybrid

Brookhaven should adopt a tiered approach. For every heart failure patient, the discharge process will adopt Project RED's core components: a follow-up appointment booked before discharge within seven days, teaching spread over the stay with teach-back, a written after-hospital plan the patient can read easily and a pharmacist call within three days that includes checking whether medications were obtained. For patients identified as high risk by the score and screen from Module Two, a transitional care nurse will add Coleman's coaching approach, with a home visit and phone calls over four weeks focused on the four pillars, and will have authority under a protocol to adjust diuretics with the cardiology team when weight rises. This borrows the Naylor model's clinical responsiveness without its full cost.

Fidelity and Adaptation

Combining models risks losing what made each one work. The components most likely to drive results, such as teach-back, appointments booked before discharge, coaching that builds skills rather than doing tasks for the patient and a responsive clinician when symptoms worsen, will be treated as fixed. Other elements, such as the number of phone calls or the format of the care plan, can be adapted to Brookhaven's rural population. A fidelity checklist will track whether each fixed component is delivered for each patient, and results will be compared with the original trials. If readmissions do not fall, the first question will be whether the components were delivered as designed.

Conclusion

No single model fits Brookhaven's causes and resources. Project RED standardizes discharge for every patient, the Care Transitions Intervention builds self-management for those at highest risk and the Naylor model's clinical responsiveness informs the protocol for acting on weight gain. Combined in tiers and delivered with attention to fidelity, these components target the causes the analysis identified at a cost the hospital can sustain.

Costs were estimated before the recommendation was finalized. The universal tier requires about thirty minutes of pharmacist time per patient and scheduling support already funded, while the high-risk tier requires one additional transitional care nurse to reach the roughly 120 patients a year expected to qualify. At Brookhaven's average cost per heart failure readmission, preventing about fifteen readmissions a year would offset the added nurse's salary, a target well within the reductions reported in the three trials.

References

Coleman, E. A., Parry, C., Chalmers, S., & Min, S. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. https://doi.org/10.1001/archinte.166.17.1822

Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., Forsythe, S. R., O'Donnell, J. K., Paasche-Orlow, M. K., Manasseh, C., Martin, S., & Culpepper, L. (2009). A reengineered hospital discharge program to decrease rehospitalization: A randomized trial. Annals of Internal Medicine, 150(3), 178-187. https://doi.org/10.7326/0003-4819-150-3-200902030-00007

Naylor, M. D., Brooten, D. A., Campbell, R. L., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatrics Society, 52(5), 675-684. https://doi.org/10.1111/j.1532-5415.2004.52202.x