In order to implement TCM in a new organization, existing staff or new staff  need to be recruited and prepared to work effectively in the role of the Transitional Care Nurse.  In addition, the organization needs to develop clear guidelines for patient selection and tools for communicating about the TCM program with patients, family caregivers and health professionals involved in the patient’s care.

The Transitional Care Nurse is a very different position than a traditional nursing position as it incorporates the skills of a nurse, care manager, and patient advocate.  In addition, the position requires experience in the use of evidence-based care, managing complexity, palliative care, active engagement of family caregivers, interdisciplinary team care, theories and strategies for individualized care and behavioral change, quality improvement, and organization, delivery and financing of services across an episode of acute care.

Characteristics needed to successfully fill this role include:

• Strong clinical skills including an understanding of and ability to implement evidence-based care
• Understanding of the health care system and its component parts including sites of care, delivery models, and the roles of various providers and health care professionals
• Ability to manage patient complexity and multiple patients with diverse needs
• Comfort with an independent role
• Experience in providing care in a hospital and home setting
• Flexibility and adaptability
• Assertiveness, maturity, and confidence
• Ability to think broadly and longitudinally, constantly assessing and anticipating the needs of the patient and his/her environment
• Effective communication skills, demonstrating both good listening and verbal and non-verbal communication skills
• Natural collaborator facilitating relationships and consensus among the patient, family, and multidisciplinary providers

This new role can provide an important option in the career ladder for nurses.  The holistic and autonomous nature of the Transitional Care Nurse is an attractive position to nurses seeking a challenging and very vital role in assisting vulnerable patients to manage complex chronic illnesses.

It takes, on average, one month to orient a new Transitional Care Nurse to the role.  The team at Penn has developed a series of web-based training modules that prepare nurses to become Transitional Care Nurses.  In addition to the web-based training modules, the Transitional Care Nurse receives training on the clinical information system designed specifically by the Penn team to support clinical operations and standardize patient information. 

Throughout the implementation of the model, Transitional Care Nurses receive on-going access to clinical nursing experts and each other through weekly clinical case conferencing sessions.  A team of multidisciplinary experts including a physician, pharmacist, social worker, and geropsychiatric nurse specialist is available as needed to help address complex issues.  These sessions provide the Transitional Case Nurses with the opportunity to discuss clinical cases, provide support to one another, and foster mentorship among one another.

The Penn team has formed partnerships with Aetna Corporation and Kaiser Permanente to diffuse this evidence-based model into a health insurance organization and integrated health system.  Kaiser is also testing the use of BSN-trained nurses and paired BSN and MSN nurses in the role of the Transitional Care Nurse.

With the support of a number of foundations (The Commonwealth Fund, Jacob & Valeria Langeloth Foundation, The John A. Hartford Foundation, Inc., the Gordon and Betty Moore Foundation, and the California HealthCare Foundation), efforts are underway to translate TCM into large health delivery systems.

Nationally, both public and private payers have created incentives to reduce readmission rates for certain diagnoses, which creates a strong rationale for implementing a model like TCM that helps reduce readmissions.

For example, the Centers for Medicare and Medicaid Services (CMS) have announced a focus on readmission rates under the Quality Improvement Organization (QIO) Program’s 9th Scope of Work (SOW), which begins August 1, 2008.  Similarly, The Home Health Quality Improvement (HHQI) National Campaign 2007, home health care providers have been oriented to a common goal of reducing hospital readmissions.  A Home Health Pay-for-Performance demonstration planned for 2008 will effectively incentivize providers to reduce acute care hospitalizations.  Together, these policy directions signal an opportunity for providers and other health care stakeholders interested in replicating TCM.