Transitional Care…It’s Time to Think Differently

  • Posted on Oct 25, 2021

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:

  • Screening for adults at high risk for poor outcomes in the transition from hospital to home
  • Staffing with advanced-practice RNs who take primary responsibility for managing care
  • Maintaining relationships with patients and families to establish trust
  • Engaging patients and caregivers in the design and implementation of care plans
  • Assessing and managing risks and symptoms
  • Educating patients and families and promoting self-management
  • Collaborating to establish agreement on care plans
  • Promoting continuity to avoid breakdowns in care after patient transitions to home
  • Fostering coordination to ensure communication between providers within the healthcare organization and those who are community-based.

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.