At hospital admission, eligible patients are assigned a Transitional Care Nurse, who conducts a comprehensive assessment of patient and family caregiver needs, coordinates the patient’s discharge plan with the family and hospital provider team, implements the plan in the patient’s home, assists the patient with management of their care needs, and facilitates communication and the transition to community providers and services. 

The Transitional Care Nurse is available to the patient seven-days per week through home visits and telephone access for one to three months of home follow-up (two months on average).

The TCM targets cognitively intact older adults with 2 or more risk factors including poor self-health ratings, multiple chronic conditions, and history of recent hospitalizations. In addition, the TCM is currently being tested among cognitively impaired hospitalized older adultsi and long-term care recipients being transferred to and from acute care hospitalsii.

Over the past 20 years, a multidisciplinary team based at the University of Pennsylvania has been testing and refining TCM.  To date, researchers have tested the model at both large academic medical centers and community hospitals in Philadelphia and surrounding counties.  TCM has been the focus of one current and three completed National Institutes of Health (NIH) funded randomized controlled clinical trials (RCTs).iii

The TCM is designed to help older adults coping with multiple chronic conditions and health risks to successfully transition from acute care into the home or other less intensive care settings (e.g., skilled nursing or rehabilitation facilities).  Studies are underway to expand testing the model among older adults in long-term care transitioning to and from acute settings.ii