Key Elements

TCM includes ten essential elements:

1. The Transitional Care Nurse (TCN) as the primary coordinator of care to assure consistency of provider across the entire episode of care;

2. In-hospital assessment, preparation, and development of an evidenced-based plan of care;

3. Regular home visits by the TCN with available, ongoing telephone support (seven days per week) through an average of two months post-discharge;

4. Continuity of medical care between hospital and primary care physicians facilitated by the TCN accompanying patients to first follow-up visits;

5. Comprehensive, holistic focus on each patient's needs including the reason for the primary hospitalization as well as other complicating or coexisting events;

6. Active engagement of patients and their family and informal caregivers including education and support;

7. Emphasis on early identification and response to health care risks and symptoms to achieve longer term positive outcomes and avoid adverse and untoward events that lead to readmissions;

8. Multidisciplinary approach that includes the patient, family, informal and formal caregivers are part of a team;

9. Physician-nurse collaboration; and

10. Communication to, between, and among the patient, family and informal caregivers, and health care providers and professionals.