The Transitional Care Model (TCM) is a care management strategy proven to enhance the care experience, improve health and quality of life outcomes and reduce total costs of care among at-risk, chronically ill older adults.
The heart of the model is the Transitional Care Nurse who follows patients from the hospital into their homes. While TCM is nurse-led, it is a multidisciplinary model that includes 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.
The Transitional Care Model has nine components:
Germantown Home recently hosted a webinar to discuss the future of transitional care. To learn more about this strategy, please click the video to watch.
Mary D. Naylor, PH.D., RN, FAAN, is the Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. Naylor leads a multidisciplinary team of clinical scholars and health services researchers in generating and disseminating evidence to enhance the care and outcomes of chronically ill older adults and their family caregivers. She is the architect of the Transitional Care Model, a care management approach proven in multiple NIH clinical trials and foundation sponsored translational efforts to improve older adults’ experience with care and health outcomes while decreasing use of costly health services. In recognition of her significant and sustained contributions to science and health care, Naylor has received multiple honors including election to the National Academy of Medicine and AcademyHealth’s Distinguished Investigator Award. She is a board member of leading health and quality organizations in the U.S.