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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.