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New open online course focused on transitional care

Engage in a world-wide community of innovators, delivering high quality care.

Penn Nursing is proud to offer a new, open online course, Foundations in Transitional Care:  The Transitional Care Model. The course is designed for nurses, especially advanced practice registered nurses, and other health care professionals seeking to improve care systems by implementing the Transitional Care Model (TCM). The TCM is a nurse coordinated, team-based care model proven in multiple NIH funded clinical trials to improve the health outcomes of older adults coping with complex care needs while reducing health care costs.

Managing transitions in care for older adults and their family caregivers, no matter the care setting, is especially challenging in a rapidly changing healthcare system. The principles included in this course will empower clinicians working with “at risk” populations, beyond older adults and their caregivers, to successfully manage transitions across health care settings and through stages of illness severity. Nurses are well positioned to be key influencers and leaders of these transitional care processes; this course will prepare them for this important and essential role.

Along with course instructors Mary Naylor and Kathleen McCauley, Elizabeth Shaid teaches several ...Along with course instructors Mary Naylor and Kathleen McCauley, Elizabeth Shaid teaches several sections, informed by her role as a transitional care expert over the last decade. In addition to describing best practices to implement the TCM, Ms. Shaid provides a deep dive into the roles and responsibilities of various team members, and strategies to achieve the TCM core components and measure program's success.

This unparalleled educational opportunity enables participants to engage in a world-wide community of like-minded innovators and to learn how to deliver high quality care that can enhance patient experiences, improve outcomes and make better use of limited resources. In this new self-paced format, participants are able to engage in knowledge and skill building whenever and wherever they want. Course participants will gain an understanding of risk factors that commonly affect at-risk patient populations as well as specific strategies, tools and techniques to assess patients’ priority needs, identify and help meet patients’ health goals and prevent future acute health problems. An emphasis is placed on lessons learned in the application of the TCM over two decades:  engaging older adults and family caregivers as team members, fostering advanced care planning, promoting shared decision-making and adherence, measuring patients’ progress, and fostering continuous improvement.

This course takes approximately 25 hours to complete and uses multiple approaches to learning including video vignettes, video lectures, readings, and case studies based on information gleaned from studies of the TCM and other evidence-based transitional care approaches. At the completion of the course, participants will have a comprehensive knowledge of delivering services consistent with the TCM. The course is graded on a pass/fail basis. Students who pass the course will receive 25 continuing education units from the Pennsylvania State Nurses Association, an accredited approver designated by the American Nurses Credentialing Center’s Commission on Accreditation (Approval # 124-3-H-15). All registered students will also receive a Certificate of Completion.

Register today

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