Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care

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Transitional care incorporates actions to ensure the coordination and continuity of care between provider settings (ie, hospitals, nursing homes, home health care, patients’ home, and physician offices) occurs to meet the patient’s goals relative to their disease management. The evolution of transitional care over the past decade has facilitated the emergence of several transitional care models. However, there is a dearth of understanding related to the collaboration between nurse transition coaches and home care nurses when implementing transitional care model activities to achieve desired patient outcomes in the home health care setting. This case study describes the enactment of a specific transitional care model’s conceptual framework to derive an in-depth understanding of the collaborations between nurse transition coaches and home health nurses in the unique context of home health care. The case is a specific patient-centered Care Transitions Intervention (CTI) model with 4 embedded subunits: (1) the experiences and actions of the nurse transitions coach, (2) the experiences and actions of the home health nurse, (3) document and artifacts review, and (4) the experiences and observations of key leadership stakeholders involved in transitional care activities in one home health care organization located in Michigan.