Consumer & Family

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 treatment plans, TCM emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management. This is all accomplished with the active engagement of patients and their family and informal caregivers and in collaboration with the patient's physicians.

Every patient participating in TCM receives individualized care guided by evidence-based protocols. While the elements of the protocol are standard, the Transitional Care Nurse tailors specific interactions and interventions with each patient based on his/her unique circumstances.

The Transitional Care Nurse (TCN)

The heart of this model is the Transitional Care Nurse (TCN), who follows each participating patient from the hospital into his/her home, and using an evidence-based care coordination approach, provides services designed to streamline care, prevent decline, and avoid rehospitalization. The TCN collaborates with physicians, nurses, social workers, discharge planners, pharmacists and other members of the health care team in the implementation of care. Every patient who participates in TCM receives individualized care based on tested practices with a unique focus on meeting patients' and caregivers' goals and increasing their ability to manage the patient's care.

Paying for TCM

Typically, this program is provided to patients under an existing health care benefit (e.g., insurance policy, state or federal plan, etc.) so that patients incur no additional costs. Each patient continues to be responsible for paying any applicable premiums, co-payments, co-insurance, or other cost-sharing for covered services that he/she receives under his/her health plan, insurance policy, or state/federal benefit.

Coordination with Primary Care Physicians and Specialists

The TCN contacts each patient's doctors to let him or her know that the patient is receiving care through TCM. The TCN will work with these doctors as the medical plan of care is developed and implemented. Additionally, with each patient's permission, the TCN will accompany the patient on doctor visit(s) to discuss the treatment plan. Throughout, the TCN updates each patient's doctors on the progress he/she has made. After an average of 2 months of TCM and when the patient is no longer at risk of hospital readmission, each patient is smoothly and effectively transitioned out of TCM with appropriate ongoing health care and support services.

TCM Complements Other Important Health Care and Social Services

A number of more traditional services for chronically ill patients are provided by hospitals, home care agencies, and disease management programs. For example, discharge planning is typically conducted near the end of a hospitalization for patients to ensure that they have appropriate placement and follow up services. However, discharge planning services generally do not extend beyond the hospitalization nor do they continue to serve patients in their homes. Similarly, home health care includes skilled care services, including nursing, physical, occupational therapy and speech-language therapy, which are aimed at providing treatment for an illness or injury. However, patients must meet certain criteria (e.g., unable to leave home unassisted) to be eligible for home care under Medicare. TCM services extend to patients who would be ineligible for care under the Medicare home health benefit and provide for greater frequency, duration, and intensity of services after hospitalization.