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Foundations of Transitional Care Seminar

The Foundations of Transitional Care seminar orients nurses and other health team members to evidence-based tools and strategies needed to redesign care for older adults and their family caregivers. This preparatory seminar is conducted online, facilitated by live webinars that focus on the core components essential to develop and implement an evidence-based transitional care program into your health system or community. The Foundations seminar begins with an overview of transitional care and the evidence-base that led to the development of the Transitional Care Model TCM).

  • Understanding TCM Components and Tools.  The seminar consists of four learning modules supported by a live 60-minute webinar and other required learning activities. To fully explore and understand each topic, the learner should expect to spend approximately 20-25 hours over the duration of the seminar to complete all readings, interactive media, exercises and practicum assignments.
  • Applying TCM to Individual Patients.  Answering the questions for whom? and how does the TCM benefit patients and their family caregivers? is the primary focus of the second and third modules. Through a series of individualized learning activities, each participant will gain an understanding of the factors that are common across high-risk patient populations as well as specific strategies, tools and techniques to assess each patient’s priority needs, elicit and meet each patient’s health goals and prevent future acute health problems. Emphasis will be placed on lessons learned in application of the TCM related to engaging older adults and family caregivers, fostering advanced care planning and promoting shared decision-making and adherence, measuring individual’s progress and fostering continuous improvement.
  • Incorporating TCM in System Redesign.  Through out each module, we focus on implementation of the TCM into your health system or community, emphasizing building the workforce and information capacity to implement evidence-based transitional care. Additionally metrics, decision support tools, and mechanisms to continuously monitor this service, improve performance, evaluate this service line and promote a sustainable program are explored.