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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 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.