The Transitional Care Model (TCM)

The Transitional Care Model (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions.

For the millions of Americans who suffer from multiple chronic conditions and complex therapeutic regimens, TCM emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management - all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient's physicians.

Q: Why did you implement this care delivery model?
This model directly responds to the most threatening health care problems facing this nation�the rapidly growing number of chronically ill patients and the disproportionate rate of health care expenditures (e.g., hospitalizations) among these patients. For that reason, TCM serves both a quality of care need and a policy imperative.
Mary D. Naylor, PhD, RN, FAAN
Marian S. Ware Professor in Gerontology
Director, NewCourtland Center for Transitions & Health
University of Pennsylvania School of Nursing