TCM Training

COURSE INFORMATION AND REGISTRATION
The purpose of this course is to educate nurses with current clinical expertise to function effectively as transitional care intervention nurses. Nurses who successfully complete this course will be eligible to assume a position as a TCN, and implement the findings from the TCM program of research into real world clinical applications. Successful performance in the TCN role is predicated upon the full understanding of the core TCM principles and a solid integration of these principles into their role.

PURPOSE
The focus of this course will be to educate nurses with current clinical expertise to function effectively as Transitional Care Model intervention nurses. Nurses who successfully complete this course will be eligible to assume a position as a TCM nurse and implement the findings from the Transitional Care Model program of research into real world clinical applications. Successful performance in the TCM nurse role is predicated upon full understanding of the core TCM principles and strong integration of these principles into whatever clinical role is assumed.

OBJECTIVES
At the completion of this course, the learner will achieve the following objectives:
1. Discuss the core components of the Transitional Care Model (TCM) and demonstrate translation of them into clinical practice.
2. Identify gaps in current clinical knowledge related to management of high risk chronically adults; correct these gaps via study of state of the science evidence based guidelines and other references.
3. Integrate knowledge of the TCM model into state of the science knowledge of management of common chronic health problems to develop plans of care to manage the transition of these high risk elders from hospital to home, including temporary stay in rehabilitation or skilled nursing facility.
4. Develop skill in accurately documenting patient assessments, patient goals, TCM nurse intervention and patient outcomes according to whatever documentation system exists in the agency.
5. Synthesize knowledge of TCM and advanced clinical practice to position the learner for adopting a new role as a TCM nurse.
6. Clearly articulate key components of the role and its value to the organization to key stakeholders (patients and families, health care providers, administrators, insurers and policy makers).

TARGET AUDIENCE
Bachelor's or Master's prepared nurses with current clinical experience in the care of chronically ill adults.

CONTENT OUTLINE
The course will consist of 6 teaching units and an orientation session. Each unit is comprised of learning activities, e.g., video presentations, reading assignments, written assignments, and a corresponding quiz. Teaching strategies will include: live web based lectures and discussion groups, audiovisual media, copies of relevant research articles, patient case histories and links to state of the science practice guidelines. This will be supported by 6 live 90 minute-webinars hosted by Penn TCM experts. Aditionally learning communities focused on clinical or administrative application will be formed.

Unit 1: Evidence Based Transitional Care for Chronically Ill Older Adults
Unit 2: Screening & High Risk Criteria
Unit 3: Comprehensive Assessment
Unit 4: Core Principles
Unit 5: Implementation: Integrating Resources
Unit 6: Achieving Quality & Value

COURSE MATERIALS
Required materials will be provided after registration via the course web site. Suggested readings can be obtained from public domain internet sites.

EVALUATION METHODS
1. A pre-assessment of TCM knowledge will be administered in a web based format to all learners prior to beginning the modules.
2. Concurrent testing will assess knowledge at the end of each module. This will enable the learner to re-learn content prior to moving on to the next module.
3. Learner satisfaction with the teaching modules will be assessed for both individual modules and the entire sequence.
4. Completion of 2-3 case studies

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