Transitional Care Nurses (TCN) - Orientation

Training for Staff in New Nursing Roles

It takes, on average, one month to orient a new TCN to the role. The team at Penn has developed a series of web-based training modules that prepare nurses to become TCNs. The core modules are designed in an independent instructional learning format with interactive modules that enable ongoing exchanges with multidisciplinary experts. Two module sets are available - one aimed at transitional care with cognitively intact patients; the other on care for cognitively impaired patients. These modules are currently being tested and will be available at a future date. In addition to the web-based training modules, the TCN receives training on the clinical information system designed specifically by the Penn team to support clinical operations and standardize patient information.

Throughout the implementation of the model, TCNs receive on-going access to clinical nursing experts and each other through weekly clinical case conferencing sessions. A team of multidisciplinary experts, including a physician, pharmacist, social worker, and geropsychiatric nurse specialist, are available as needed to help address complex issues. These sessions provide the TCNs with the opportunity to discuss clinical cases, provide support to one another, and foster mentorship among one another.

The Role of Technology

The Penn research team developed a web based clinical information system that houses all of the evidence-based assessment tools, intervention protocols, and charting for the Omaha System, a standardized language for documenting patient problems and nursing interventions. The system is also used to track the patient's visits, medications, and symptoms and delivers the evidence-based protocols to the point of care. Web-based training modules are offered to nurses in conjunction with the clinical information system.

Teamwork and Communication

A key lesson from the provision of this model to more than 1,500 patients involved in the team's studies is the importance of a multidisciplinary approach. TCNs coordinate and collaborate on care among and between different settings of care and different professionals including, but not limited to, physicians, care managers, discharge planners, pharmacists, therapists, social workers, and spiritual counselors. Strong collaboration with all providers contributes to a streamlined and rational plan of care for the patients.