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


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


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.

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).

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

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.

    Surya Kolluri, Head, TIAA Institute, Colbert Narcisse, Chief Product and Business Development Officer, TIAA, Mary D. Naylor, Marian S. Wa...

    Penn Nursing Professor Mary Naylor Speaks at WSJ Future of Everything Festival

    Center Director and University of Pennsylvania School of Nursing Professor Mary Naylor participated in a panel discussion on the topic of longevity literacy and its connection to achieving longevity fitness this week in NYC a a part of The Wall Street Journal’s Future of Everything Festival, alongside Surya Kolluri, Head of TIAA, and Colbert Narcisse, Chief Product and Business Development Officer at TIAA.

    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.

    George Demiris and Ashish Shah

    Technologies for Aging and Caregiving: Challenges and Opportunities

    In a recent webinar, George Demiris, PhD and Ashish Shah shared their experiences developing, testing, and implementing technologies that could improve the home as a care setting and help caregivers assess and address their loved one’s needs.


    Penn Nursing Center Joins with 50 Leading National Organizations to Curb Infodemic of Health and Science Misinformation and Disinformation

    The creation of The Coalition for Trust in Health & Science, was formally launched during the 2023 American Association for the Advancement of Science (AAAS) Annual Meeting in Washington, D.C. The alliance, which includes Penn Nursing’s NewCourtland Center for Transitions and Health, was formed to unite leading organizations from across the entire health ecosystem to advance trust and factual science-based decision-making. NewCourtland Director, Mary Naylor, PhD, RN, the Marian S. Ware Professor in Gerontology, is part of the Core Convening Committee which spearheaded the creation of the Coalition.


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.

Contact us

Penn also offers group discounts on TCM courses to prepare and orient organization team members to implement TCM.