Volunteer Nursing Experience in Promoting Holistic Long-Term Care by Applying Transitional Care Model for Older Adults

Abstract

Transitional care is vital in long-term elderly care, encompassing planning from routine conditions to crises, referrals, and home-based care. This article explores promoting comprehensive long-term health care for seven socially marginalized elderly individuals by volunteer nurses using Naylor's model transitional care.  The volunteer nurses offered continuous telephone counseling to foster independence and improve quality of life. Drawing from their experiences, the article aims to empower caregivers with insights into transitional care principles for sustained support. Over two years, elderly individuals primarily sought consultations for chronic health issues, emergencies such as strokes and heart attacks, and matters like estate planning and last wills and testaments. Providing this type of care demands expertise in health assessment, collaborative family planning, goal setting, home and hospital visits, guidance, education, self-care resources, and financial support. The volunteer nurses employed various communication channels and clinical skills, including video calls, to coordinate during home emergencies. Results indicated increased happiness and independence for five elderly individuals. One out of the seven required ongoing care due to post-surgery complications, and another one passed away during recovery after a cardiac catheterization procedure. The care outcomes explored in this study align with Naylor's transitional care model, emphasizing the effectiveness of long-term care strategies.