Transitional Care Model

In efforts to address the health care needs of an individual with MCC, health care systems benefit from using the Chronic Care Model (CCM) and Transitional Care Model (TCM) when developing a patient care plan. The CCM predicts an increase in patients with self-management skills and tracking systems, by streamlining medical care through partnerships between health systems and local community assets (Mackey, Parchman, & et al., 2012). The TCM “emphasizes recognition of patient's’ health goals, coordination and continuity of care during acute episodes of illness, and development of streamlined plan of care to prevent future hospitalizations” ("Transitional Care Model," 2014, para. 1). Both models are successful with active participation of

patients and their families and in collaboration with the patient’s physicians and interdisciplinary team members. Patients who receive care modeled after the CCM and TCM have reported improvements in physical health, functional status and quality of life. Seton Total Health (STH) Clinic is a transitional care program, working within the TCM and CCM care framework, focuses on reducing the amount of emergency room visits and readmissions related to poor functional status and cognitive impairment.