Managing transitions in care, especially among elderly patients, enhances patient experiences, improves health and quality-of-life outcomes, and represents wiser use of finite resources. Transitional care includes a range of time-limited services designed to ensure health care continuity and prevent poor outcomes among at-risk populations as they move from one level of care to another, among multiple health care team members, and across settings, such as hospitals to homes.

In this course, students learn about the research, policy, and practice implications of this model of care. 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 self-paced online format, participants are able to engage in knowledge and skill building whenever and wherever they want. 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.

Christina Whitehouse, PHD, CRNP, a TCM clinical expert, is featured throughout the course, working with a patient and their family caregiver as a team to address their immediate and longer-term health and wellness goals.

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. At the completion of the course, participants will have a comprehensive knowledge of delivering services consistent with the TCM.

An emphasis is placed on lessons learned in the application of the TCM over two decades, including:

• 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.