Innovative Models of Care: Transitions in Care Team

Nature and scope of the project

The intent of this project is to create an innovative nursing model of care to facilitate patient throughput win an additional level of nursing care to facilitate the transitions of the patient. The development of the Transitions in Care Team (TiCT) nurse will support the clinical nurse and multidisciplinary care team. With the increased nurse to patient ratios and workload of clinical nurses, this model can mitigate stress, staff turnover and enhance colleague resiliency. This innovative model of care would support strategic goals by increasing timely access to healthcare, promoting and supporting bedside care providers thus reducing staff turnover, promoting colleague engagement and improving patient satisfaction.

Synthesis and analysis of supporting literature

•Hughes, R., Meadows, M. T., & Begley, R. (2022). American Organization for Nursing Leadership Nurse leader Core Competencies. JONA: The Journal of Nursing Administration, 52(12), 629– 631. •Project Management Institute. (2017). A guide to the Project Management Body of Knowledge: (Pmbok Guide) (6th ed.). •Stanley, D., Malone, L., & Shields, L. (2016). Project Management supports the change process. Nursing Management, 47(6), 52- 55.

Project implementation

This innovative model of care was an operational decision developed to support the transition of patients within the organization. Initially, four medical/surgical/telemetry units were chosen to test this model as they had the highest impact on the organization in terms of throughput. A job description with roles and responsibilities was developed. A competency and orientation were created. Metrics that supported the role were outlined and baseline data was collected. The decision was made track the percent of patients discharged within 150 minutes of discharge order and the time an ICU downgrade is taken to a lower level of care inpatient unit and 105 minutes of and ICU downgrade from the time a clean and ready bed assigned until the patient arrived in the assigned bed.

Evaluation criteria

Discharge of patients from time of order to time of departure in under 150 minutes.

ICU downgrades from the time of a clean and ready bed assigned to the arrival of the patient in under 105 minutes.


Within eight months of initiating the TiCT model of care, the data showed notable improvement in the ability to impact throughput.


Based on evaluation of the role and demonstrated outcomes, the recommendation is to implement this role on all medical/surgical/telemetry units within the organization.



Innovative Models of Care: Transitions in Care Team