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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 our work. 

Simulating the TCM

In partnership with the Stevens Institute of Technology, the TCM research team is exploring use of policy flight simulators…(read more)

Foundations of Transitional Care Seminar

Register today for an upcoming section. This online program with live webinars with TCM experts, orients and prepares nurses and other health team members to evidence-based tools and strategies needed to redesign care for older adults and their family caregivers.  The seminar consists of four modules supported by a live 60-minute webinar and other required learning activities (readings, media, exercises and practicum assignments). 

Contact us for your organization’s learning and development needs in transitional care.  We also offer group discounts and the opportunity to create a section for your organization only.