In response to the growing number of chronically ill older adults and the disproportionate rate of health care expenditures and hospitalizations among the chronically ill, policymakers, payers, and other health care stakeholders have recommended national action to improve the coordination of care. The Transitional Care Model (TCM) responds to this national imperative and was specifically developed to address the negative outcomes associated with breakdowns in care when older adults with complex needs transition from an acute care setting to the home or other care settings.

Specifically, the model aims and has been shown to achieve the following outcomes:

• Improve post-discharge health outcomes
• Enhance patient and family caregiver satisfaction
• Prevent unnecessary emergency room visits
• Prevent avoidable rehospitalizations for primary and co-morbid conditions
• Reduce total number of days rehospitalized and the readmission charges
• Decrease health care costs
• Improve post-discharge clinical outcomes including quality of life, physical function, and safety
• Manage needs, symptoms, and therapies associated with multiple, serious co-existing conditions

Clinical and health services scholars at the University of Pennsylvania in Philadelphia, Pennsylvania designed and tested the TCM. The model was first piloted in 1989.

The multidisciplinary team at the University of Pennsylvania has devoted itself to understanding and improving care for chronically ill older adults by studying and adapting the model, investigating its short- and long-term benefits, and developing and disseminating implementation tools to facilitate its widespread, national adoption.

In total, approximately $10.3 million (total costs) has been received in support of the development and testing of this evidence-based protocol for both cognitively intact and impaired patients. To date, the research team at University of Pennsylvania has been awarded $8.1 million (total costs) from the National Institutes of Health, National Institute of Nursing, and the National Institute of Aging to test and refine the model. In addition, the Penn research team has received numerous non-federally supported awards, approximately $2.2 million (direct costs) in support of the development of components of the TCM. With the support of the Pew Charitable Trusts, the Penn research team has expanded testing of the model with community-based young adults with serious physical disabilities.

Translational efforts testing the application of the TCM in the real world of clinical practice are currently underway (see section on Implementation and Replication).