Who Benefits?
"The thing that struck me about [TCM] was that it made so much sense. It clearly improved the patient and family's care experience. It had evidence...it had been researched. There was science behind it. And the outcomes were terrific. Not only were patients pleased with the Transitional Care Nurse, but it improved quality as we measure it and it also led to lower costs...This is an example of great innovation."
Richard D. Della Penna, MD, Medical Director, Kaiser Permanent Aging Network, Oakland, CA
The Transitional Care Model targets cognitively intact older adults with two or more risk factors, including history of recent hospitalizations, multiple chronic conditions or medications, and poor self-health ratings. In addition, TCM is currently being tested among cognitively impaired hospitalized older adults4 and long-term care recipients being transferred to and from acute care hospitals5.
Role of the Patient and Family
Patients and their informal caregivers, including family members and the extended support system, are TCM's central focus. The model is entirely patient- and family-focused and creates and sustains an enduring, continuous, trusting, and healing relationship among and between patients, family caregivers and the Transitional Care Nurse. This is this accomplished through the identification of patients' and caregivers' goals, development and implementation of individualized plans of care, application of effective communication, and the adoption of evidence-based care.
Access to TCM
While over 20 years of research and testing have contributed to this innovative model, currently, TCM is available in limited markets. Under the Penn leadership team's stewardship and in partnership with several major health plans and insurers, TCM will soon be more widely available to those who will benefit the most. To ensure that this established evidence-based model is accessible, efforts are underway to support its replication, establish national policies that enable rapid translation, and disseminate TCM's favorable outcomes.
TCM provides evidence-based comprehensive in-hospital planning and home follow-up of chronically ill high-risk older adults hospitalized for common medical or surgical conditions. Emphasis is placed on coordination and continuity of care, prevention and avoidance of complications, close clinical treatment and management, and ongoing communication, education, and support.
4 Naylor MD, Principal Investigator. Hospital to Home: Cognitively Impaired Elders and their Caregivers. National Institutes of Health, National Institute on Aging, Grant No.: R01AG023116, 2005-2010.
5 Naylor MD, Principal Investigator. Transitional Care of Hospitalized Nursing Home Residents. Rand-Hartford Center for Interdisciplinary Geriatric Health Care Research, University of Pennsylvania School of Nursing, 2005-08.