Table 2

Adaptation of TCM modules to the TIGER study intervention group in German healthcare setting

Intervention module/component as defined in TCM according to Hirschman et al22  Component adapted to setting in the TIGER study
(1) Screening of patients:
screening for adults transitioning from hospital to home who are at high risk for poor outcomes
  • For the randomised controlled TIGER study, a-specific IT tool supported screening for potential participants electronically via the patient management system of BBR according to the eligibility criteria age, health insurance and residence within a 50 km radius. All further eligibility assessment and recruitment was performed in person by the TIGER staff. Directly after recruitment, the participants were randomised to either intervention or control group via the electronic data acquisition and eCRF system.

(2) Staffing for care planning and management:
master’s prepared APRN assume primary responsibility for care management of patients throughout episodes of acute illness
  • Four full-time care professionals with at least 5 years of care experience with geriatric patients, each of them with additional complementary skills for the team (registered nurses, occupational therapist, case manager and head nurse) and specifically trained for the intervention of this study are employed by BBR.

  • Each IG patient is supported by one designated pathfinder during the intervention period. If complementary skills advice is needed, the pathfinder will find this within his pathfinders team or within the collaborating care team of his patient.

(3) Maintaining relationships:
establishment and maintenance of a respectful, trusting relationship with the patient and family caregivers, including home visits, telephone calls, availability of the APRN in charge of the intervention 7 days a week
  • Establishment of respectful, trusting relationships starts in the hospital (already prior to T0 in the recruitment process) and is deepened throughout the intervention in home visits and telephone calls. A trusting relationship enables the identification of problems, needs, anxieties, as well as risks and symptoms.

  • According to German working hour acts, the pathfinders will be available from Monday to Friday, not 7 days a week. The participants and their caregivers receive a telephone number of the pathfinder office, so that they can call the pathfinders with any occurring questions or problems. On weekends, when the office is closed, participants and their caregivers are instructed in detail how to leave a message on the pathfinder’s answering machine and how to call the hospital’s emergency department if immediate assistance is needed. On early Monday mornings, the pathfinders contact every person that has left a message on the answering machine to trace back everything that occurred over the weekend.

(4) Engaging patients and caregivers in care management planning and implementation:
engaging of patients and their caregivers in design and implementation of the plan of care aligned with their preferences, values and goals, in collaboration with the medical team
  • In developing the care plan in close collaboration with the participant, his/her caregivers, and care team, the care plan includes the measures and activities planned and initiated by the hospital discharge planning team and integrates them with the ambulatory care measures. Additionally, the pathfinders make sure to respect and integrate the participant’s individual preferences, values and goals.

(5) Assessing/ managing risks and symptoms:
identifying and addressing the patient’s priority risk factors, symptoms and health status as well as complete management of symptoms to prevent onset or risks
  • Assessing, identifying and managing risks and symptoms according to individual health status and situation is performed intensively, starting in the hospital and integrating the information of the hospital. The pathfinders_ assessment is supported by a standardised questionnaire instrument based on the Neues Begutachtungs Assessment, an assessment to determine eligibility for benefits from the long-term care insurance in Germany,31 to identify individual care needs as well as to document and evaluate the needed or already initialised measures. The instrument assesses the participant’s care situation, care supply and quality by examining the participant’s living situation, mobility and falls, cognition, psychological situation, nutrition, self-support, medication, daily activities, housekeeping, vision and hearing capacities, continence, pain score, wound management, health and disease knowledgeability of participant and caregiver and caregiver burden. For each topic, the pathfinder evaluates whether or not there is a need for change, which measures would provide a remedy or whether or not already taken measures have helped to solve the problem or which amendments are needed. This instrument is applied at the first home visit and at visits T1, T2, T3 and T4.

  • Additionally, the psychosomatic situation due to loneliness, grief for a deceased and depression, is assessed.

  • Physical parameters recordings by the participant (eg, blood pressure, pain diary and weight log) are encouraged as a part of the intervention.

(6) Education/ promoting self-management:
preparing older adults and family caregivers to identify and respond quickly to worsening symptoms, meeting their learning needs
  • Participants and their caregivers are provided with an emergency plan stating whom to contact in which case.

  • Participants are encouraged and guided to recognise their own risks and symptoms, how to keep their health record updated and how to adequately contact physicians, health services, neighbourhood, and social networks, as a means of empowering self-reliant health management.

  • Healthy behaviour regarding mobility, nutrition and prevention of the onset of symptoms or risks is regularly addressed by the pathfinders, and implementation of the participant’s ideas for healthy behaviour is promoted.

(7) Collaborating:
promotes consensus on the plan of care between older adults and members of the care team
  • The pathfinders establish and facilitate efficient and trusting communication and consensus-building among the participant’s care team partners: physicians within and outside of the hospital (family physicians of the participants), hospital care and discharge planning team, ambulant care services, medical store houses, occupational therapists, physiotherapists, nutritional therapists, charity networks, municipal organisations and also the participants and their caregivers themselves.

(8) Promoting continuity:
prevents breakdowns in care from hospital to home by having the same clinician involved across these sites. Promoting continuity could help to prevent breakdowns in care across settings
  • The same pathfinder gets to know the participant and his/her situation in the hospital, establishes and advances the care plan within the care team in the hospital, at transition, and in the home-setting. The intense follow-up in the first month (see figure 1) and the follow-up of 6–12 months promote continuity.

  • In the case of readmission of the participant, the pathfinder supports continuity of care and information transfer from the ambulant care setting back into the hospital BBR again.

(9) Fostering coordination:
promotes and encourages communication and connections between the healthcare team and community-based practitioners
  • The pathfinder coordinates and fosters information exchange in the care team in the inpatient and in the home-setting, as well as across settings and regarding municipal or health insurance health course offerings.

  • Especially, the municipal and charity offerings of the city of Regensburg are manifold, but mostly not networked. The pathfinders help to connect the participants with suitable public offerings.

  • APRN, advanced practice registered nurses; BBR, Barmherzige Brüder Regensburg; eCRF, electronic case report form; TCM, transitional care model; TIGER, Transsectoral Intervention Programme for Improvement of Geriatric Care in Regensburg.