TCM in Practice

Partnership with patients, family caregivers, health care professionals, and communities


The TCM can be easily integrated into a health care system with the support of interdisciplinary leadership and proper planning. Site champions from all disciplines are needed to take part in energizing their constituencies during implementation of the TCM program and to foster necessary adaptions to current workflows by all potential departments involved with the program. Adaptation does not mean an overhaul to current workflows. Adaptation does mean creating a shared understanding about the program that is supported by effective communications about how the new program will function within the organization.

Healthcare Quality Strategies—the federally designated Quality Improvement Organization (QIO) for New Jersey—has advocated for the use of the TCM as part of the Centers for Medicare and Medicaid Services’ national initiative to reduce hospital readmissions. The project, referred to as the New Jersey Care Transitions project, was initiated among Medicare beneficiaries in defined communities in 14 states. For example, Virtua Home Care nurses received training and technical assistance in using the model from the TCM research team.


Ready to implement?

The Penn team built and tested translation tools, including patient screens, recruitment scripts, online training courses, performance improvement processes, documentation systems, and monitoring and evaluation protocols for use in practice.

View online training courses


    Two Penn Nursing Professors Selected for Induction to the International Nurse Researcher Hall of Fame

    Penn Nursing’s Eileen Lake and Salimah Meghani will both be honored by Sigma Theta Tau International for their contributions to the nursing profession during the organization’s 35th International Nursing Research Congress in Singapore, in July, 2024.

    Close up of old man holding hands of his son while sitting on the couch. Shot at home

    As People Live Longer, Family Caregivers Face Financial Challenges

    Many people overlook the short- and long-term costs of financial caregiving, a growing problem that financial advisors and employers can help address, according to a new report by the TIAA Institute and the University of Pennsylvania School of Nursing (Penn Nursing).


    Integrating the Transitional Care Model into Nurse Practitioner Curricula to Improve Outcomes for High-Risk Older Adults

    Managing transitions in care for older adults and their family caregivers, no matter the care setting, is especially challenging in a rapidly changing health care system. Patient discharges which typically require prescription writing, discharge summary creation, and team consultations for home care entail more complex coordination and planning.

    Jennifer Olsen, DrPH

    Shifting Caregivers from the Margins to the Middle: Power in Numbers

    Join CEO Jennifer Olsen, DrPH, as she discusses the Rosalynn Carter Institute for Caregivers’ (RCI) vision and strategies designed to make caregivers more central in our culture, in our policies, and in our workplaces.

    Drs. Christine Grady, Carol Taylor, and Jason Karlawish

    When the Caregiver is Also a Bioethicist and Clinician - Ethical Dimensions of Caregiving

    A daughter who cared for her mother with dementia. A wife who cared for her husband with cancer. And a son who cares for his father with dementia. In the 10th webinar in the Caregiving NOW series, three speakers shared their lived experiences as caregivers for a loved one.