Web-based Training Modules

Web-based training modules are offered to Transitional Care Nurses. The core modules are designed in an independent instructional learning format with interactive modules that enable ongoing exchanges with multidisciplinary experts. Two module sets are available—one aimed at transitional care with cognitively intact patients; the other on care for cognitively impaired patients. These modules are currently being tested and will be available at a future date. Please check the model’s website for updates. http://www.nursing.upenn.edu/ncth/

Clinical Information System

The Penn research team developed a web based clinical information system that houses all of the evidence-based assessment tools, intervention protocols, and charting for the Omaha System, a standardized language for documenting patient problems and nursing interventions. The system is also used to track the patient’s visits, medications, symptoms and delivers the evidence-based protocols to the point of care. Please visit the model’s website for additional information. http://www.nursing.upenn.edu/ncth/

Patient Eligibility Criteria

Specific criteria for selecting patients for participation in the TCM.

To be eligible for TCM, patients must be:

• Age 65 and older; English speaking; reachable by telephone; alert and cognitively intact at time of enrollment; diagnosed with a documented primary cardiovascular, respiratory, endocrine or orthopedic health problem.
• Additionally the beneficiary must meet at least two of the following risk factors associated with poor outcomes: age 80 years or older; inadequate support system(s); > 3 active, chronic health problems; history of depression; moderate-to-severe functional status impairment; multiple hospitalizations in the prior 6 months; hospitalization in the past 30 days; fair to poor self-rating of health status; and, history of non-adherence to the therapeutic regimen.
• Older adults with end-stage renal disease will be excluded from enrollment because of their unique access to special Medicare services. Patients with a severe neurological deficit; active behavioral health/psychiatric illness; or primary cancer undergoing active treatment are also excluded.

Available Resources

The Newcourtland Center for Transitions and Health Website

Provides information and updates on the Transitional Care Model.

The Quest for New Innovative Care Delivery Models

Kimball, B. et al. Journal of Nursing Administration. September 2007. 392-398.

Transitional care for older adults: a cost-effective model

Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief. 2004 Apr-May;9(6):1-4.

Transitional Care of Older Adults Hospitalized with Heart Failure

Naylor, M.D., et al. “Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial” Journal of the American Geriatric Society, Volume 52, pp 675-684, 2004.

Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders

Naylor, M.D., et al. “Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders” Journal of the American Medical Association. Volume 281 Number 7, pp.613-620, 1999.

Comprehensive discharge planning for the hospitalized elderly

Naylor, M.D., et al. Comprehensive discharge planning for the hospitalized elderly. Annals of Internal Medicine. 1994;120:999-1006.

The Transitional Care Model team prefers that interested organizations email them via the feature on their website at http://www.nursing.upenn.edu/ncth/rp/