Providers & Clinicians
Transitional Care Model is unique in several ways:
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Under TCM, the patient's home is the primary setting of care;
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TCM emphasizes achieving longer term positive outcomes by assuring that patients and their family caregivers have the knowledge and skills to recognize and address health care problems as they arise;
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TCM has been tested and refined for more than 20 years by a team of researchers from the University of Pennsylvania;
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The scientific base supporting TCM is rigorous and based three completed National Institutes of Health (NIH)-funded randomized controlled clinical trials (RCTs); and
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Results from studies of TCM consistently demonstrate significant improvements in patient safety and health care outcomes, enhancements in quality of life and satisfaction with care, and reductions in overall health care costs.1, 2, 3
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.
The Transitional Care Nurse (TCN)
The Transitional Care Nurse (TCN) follows participating patients from hospitals into their homes, and using an evidence-based care coordination approach, provides services designed to streamline plans of care and interrupt patterns of frequent acute hospital or emergency department use and health status decline. The TCN collaborates with physicians, nurses, social workers, discharge planners, pharmacists, and other members of the health care team in the implementation of tested protocols with a unique focus on increasing patients' and caregivers' ability to manage their care. Every patient who participates in TCM receives individualized care guided by evidence-based protocols.
1 Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauley M. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120:999-1006.
2 Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauley MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620.
3 Naylor MD, Brooten DA, Campell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.