Transitional Care Model
The nursing-led Transitional Care Model (TCM), pioneered at the University of Pennsylvania, has been at the forefront of evidence-based care across settings and providers.
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. This site presents the research, policy, and practice implications of the Penn team’s work.
Recent Findings
COST IMPACT
In a comparison study on postacute care and rehospitalization costs for hospitalized older adults with cognitive impairment, TCM had significantly lower costs than the Augmented Standard Care group at both 30 and 180 days, and significantly lower costs than the Resource Nurse Care at 30 days. These findings suggest that the TCM can reduce both the amount of other postacute care (i.e., skilled nursing facility stays) and the total cost of care compared with alternative services with cognitively impaired older adults. Read the full article: Cost impact of the TCM for hospitalized cognitively impaired older adults
WHAT ARE ADAPTATIONS?
Very few studies have described modifications (adaptations) to components of evidence-based interventions. The focus of this mixed-methods study funded by the Robert Wood Johnson Foundation was to describe and classify common adaptations of the TCM’s 10 components. The top 3 reported adaptations, across national survey respondents, were related to contextual adaptations. Additional interviews clarified a diverse set of reasons for such modifications. Read the full article: Adaptations of the evidence-based TCM in the U.S.
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.
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.
Consultation
Penn team experts can help your organization achieve and sustain its quality improvement efforts. Through multiple proven strategies, the team is positioned to assist your organization in developing a customized TCM program that builds upon the resources and infrastructure of your organization.
Penn also offers group discounts on TCM courses to prepare and orient organization team members to implement TCM.
