The Transitional Care Model (TCM), designed by Dr. Mary Naylor and a multidisciplinary team of colleagues at the University of Pennsylvania, addresses the negative effects associated with common breakdowns in care when older adults with complex needs transition from an acute care setting to their home or other care setting, and prepares patients and family caregivers to more effectively manage changes in health associated with multiple chronic illness. The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across health care settings and between clinicians. Throughout the rigorously conducted clinical trials and demonstration programs, nine core components have consistently emerged. 

Because the model focuses on individualized, multidisciplinary evidence-based clinical protocols that prevent decline and reduce readmission for an extended period, the TCM complements primary care provided by physicians or telephonic case management and disease management programs that typically focus only on one health condition.