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Continuity of Care: The Transitional Care Model

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Karen B. Hirschman, PhD, MSW
Elizabeth Shaid, MSN, CRNP
Kathleen McCauley, PhD, RN, FAAN
Mark V. Pauly, PhD
Mary D. Naylor, PhD, RN, FAAN


Older adults with multiple chronic conditions complicated by other risk factors, such as deficits in activities of daily living or social barriers, experience multiple challenges in managing their healthcare needs, especially during episodes of acute illness. Identifying effective strategies to improve care transitions and outcomes for this population is essential. One rigorously tested model that has consistently demonstrated effectiveness in addressing the needs of this complex population while reducing healthcare costs is the Transitional Care Model (TCM). The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. This article provides a detailed summary of the evidence base for the TCM and the model’s nine core components. We also discuss measuring the TCM’s core components and the overall impact of this evidence-based care management approach.

Citation: Hirschman, K., Shaid, E., McCauley, K., Pauly, M., Naylor, M., (September 30, 2015) "Continuity of Care: The Transitional Care Model" OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 3, Manuscript 1.

DOI: 10.3912/OJIN.Vol20No03Man01

Key words: Transitional care, transitions, older adults, multiple chronic conditions, family caregivers, care experience, health outcomes, hospitalizations, resource use, care management, evidence-based practice

Findings from multiple studies reinforce the poorly managed healthcare needs of older adults... Among the more than 20 million Medicare beneficiaries, 37% have five or more chronic conditions (Centers for Medicare & Medicaid Services [CMS], 2012). For older adults with multiple chronic conditions (MCCs), other risk factors such as functional deficits or social barriers add to the complexity of managing their healthcare needs (Anderson, 2010). As a result of frequent episodes of acute illness, this patient group (when compared to all other Medicare beneficiaries) also experiences significantly higher rates of healthcare encounters, including physician and emergency department (ED) visits and hospitalizations (Anderson, 2010; Berenson & Horvat, 2002; Pham, O'Malley, Bach, Saiontz-Martinez, & Schrag, 2009). Findings from multiple studies reinforce the poorly managed healthcare needs of older adults with MCCs as leading factors often contributing to devastating human and economic consequences (Arora et al., 2009; Krumholz, 2013; Naylor, 2012; Vogeli et al., 2007).

Six overlapping categories of problems have been associated with negative outcomes among hospitalized older adults with MCCs who transition to post-acute settings or their homes: lack of patient engagement; absent or inadequate communication; lack of collaboration among team members; limited follow-up and monitoring; poor continuity of care; and, serious gaps in services as patients move between healthcare professionals (clinicians) and across care settings (Bowles, Pham, O'Connor, & Horowitz, 2010; Naylor, 2012; Stevenson, McRae, & Mughal, 2008). Among this patient group, these system issues have been linked to poor ratings of the care experience and further declines in health status (Coleman & Boult, 2003; Naylor et al., 2004). High rates of preventable hospitalizations and ED visits are among the most burdensome consequences. In a Medicare Payment Advisory Commission (MedPAC) recent Report to Congress, all-cause 30-day rehospitalization rates for Medicare beneficiaries decreased from an average of 19% to below 18%, at least in part due to major changes in incentives (MedPAC, 2015). However, among Medicare beneficiaries with four or more MCCs, the 30-day rehospitalization rate was 36% (Lochner, Goodman, Posner, & Parekh, 2013).

While some rehospitalizations are appropriate and unavoidable, between 13 to 20% of those experienced by chronically ill older adults are conservatively estimated to be preventable (Bentler, Morgan, Virnig, & Wolinsky, 2014; Kim, Helmer, Zhao, & Boockvar, 2011; Nyweide et al., 2013). In addition to the tremendous human burden, societal costs associated with caring for these older adults are significant. In 2011, an average of $2,097 was spent annually on healthcare for Medicare beneficiaries 65 and older with up to one chronic condition compared to $11,628 for those with four to five conditions and $31,543 with six or more conditions (Lochner et al., 2013). In 2010, healthcare services for Medicare beneficiaries with four or more chronic conditions accounted for 74% of total Medicare spending (CMS, 2012).The vast majority of these costs were due to high rates of often avoidable hospitalizations and rehospitalizations (MedPAC, 2014).

The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. Care delivery approaches that target the “Triple Aim” – enhanced patient experiences, improved population health, and reduced costs – are needed (Berwick, Nolan, & Whittington, 2008; Burwell, 2015). Specifically, evidence-based transitional care, a set of time limited services provided during an episode of acute illness between and across settings, is now a recognized approach to improve care for older adults (Coleman & Boult, 2003; Krichbaum, 2007; National Transitions of Care, 2008; Naylor, 2000). The most rigorously tested of these approaches, the Transitional Care Model (TCM), has consistently demonstrated enhanced health and economic outcomes for older adults with MCCs.

The TCM is a nurse-led intervention targeting older adults at risk for poor outcomes as they move across healthcare settings and between clinicians. This article provides a detailed summary of the evidence base for the TCM and the model’s nine core components. We will also discuss measuring the TCM’s core components and the overall impact of this evidence-based care management approach.

The Transitional Care Model (TCM)

The TCM supplements care provided to patients in the hospital and substitutes for care provided by professional nurses in patients’ homes. The TCM intervention focuses on improving care; enhancing patient and family caregiver outcomes; and reducing costs among vulnerable, chronically ill, older adults identified in health systems and community-based settings, such as patient-centered medical homes (PCMHs). Over the past two decades, this nurse-led, team-based model of care, has been designed, tested, and refined by a multidisciplinary team of clinical scholars and health services researchers based at the University of Pennsylvania. The TCM emphasizes identification of patients’ health goals; design and implementation of a streamlined plan of care; and continuity of care across settings and between providers throughout episodes of acute illness (e.g., hospital to home) (Naylor et al., 1994; Naylor, 2004-2007; Naylor et al., 1999; Naylor et al., 2014). Under this model, care is both delivered and coordinated by the same master's prepared advanced practice registered nurse (APRN) in collaboration with patients, their family caregivers, physicians, and other health team members (Naylor, 2012). The TCM supplements care provided to patients in the hospital and substitutes for care provided by professional nurses in patients’ homes.

Evidence Base

Findings from three reported multi-site National Institute of Nursing Research (NINR) funded randomized clinical trials (RCTs) have consistently demonstrated the capacity of the TCM to improve acutely ill older adults’ experiences with care, and health and quality of life outcomes. Outcomes have demonstrated reduced rehospitalizations and total healthcare costs, after accounting for the additional costs of the intervention (Naylor et al., 1994; Naylor et al., 1999; Naylor et al., 2004).

Outcomes have demonstrated reduced rehospitalizations and total healthcare costs, after accounting for the additional costs of the intervention. In each RCT, the TCM was refined and the length of the intervention modified to address unique needs of increasingly complex groups of older adults with MCCs (Naylor et al., 1999; Naylor et al., 2004; Naylor et al., 2014). For example, in a RCT targeting older adults hospitalized with heart failure who returned to their homes, time to first rehospitalization was significantly improved among intervention patients who received the TCM (p=0.026) when compared to a similar control group. Compared to standard care patients, fewer all-cause rehospitalizations (104 vs. 162, p=0.047) were observed at one year post-index hospital discharge, contributing to lower mean total costs, with estimated per patient savings of $4,845 (p=0.002) (Naylor et al., 2004). While the TCM’s overall impact on resource use was significant through one year, large reductions in rehospitalizations during the first six months of follow-up that were sustained over time accounted for this difference.

In a more recent National Institute of Aging (NIA) funded study, the care experiences and health and quality of life outcomes of hospitalized, community-based, cognitively impaired older adults who received the TCM were compared to similar groups who received other evidence based interventions. In this comparative effectiveness study, older adults who received the TCM had significantly fewer all-cause rehospitalizations through six months post-index hospitalization (Naylor et al., 2014). In partnership with clinical leaders at diverse PCMHs, application of the TCM has been extended to include older adults identified in primary care settings. Pilot finding among a set of chronically ill older adults who had a hospitalization in the prior 30 days before enrollment revealed that the group who received a combined PCMH plus TCM intervention had a longer time to first rehospitalization or death than those who received the PCMH only. Findings from this pilot study reinforced the need for strong collaboration and communication among primary care clinicians, master’s prepared APRNs and patients to achieve successful outcomes (Hirschman et al., 2015).

Translating Research into Practice

In partnership with a the University of Pennsylvania Health System (UPHS) and a major healthcare insurer (Aetna), a translational research effort was conducted to determine if clinical and economic effects achieved in multi-site research projects could be replicated in “real world” healthcare systems. Findings demonstrated significant improvements in all assessed measures of health and quality of life among Medicare managed-care members who received the TCM, plus telephonic case management, when compared to a similar patient group who received telephonic case management only. Among stringently matched pairs in this study, significant decreases in the total number of rehospitalizations (p<0.05) and total hospital days (p<0.05) were observed at 90 days. A significant reduction in total healthcare costs per member per month at 90 days and a cumulative per member savings of $2,170 at one year post-enrollment (p<0.05) also were observed in the TCM intervention group, relative to the comparison group (Naylor, Bowles, et al., 2013).

Based on this work, the UPHS launched the Transitional Care Program service line with support funding from major local healthcare insurers. To date (2009 through 2014), over 800 high risk patients admitted to the UPHS have enrolled in this service line. The rehospitalization rate at 30 days is substantially below the national average for all cause rehospitalizations among Medicare beneficiaries (MedPAC, 2015) and is half that of the 30-day rehospitalization rate for Medicare beneficiaries with four or more chronic conditions (Lochner et al., 2013). Additionally, findings revealed that the positive impact on rehospitalizations has been sustained for patients through 90 days post index hospital discharge. Since February 2014, we have been assessing the effects of ongoing monitoring and follow-up of this patient group through nine months post-index hospitalization.

Transitional Care Core Components

Rigorous evaluation of interventions based on the TCM and examination of detailed case summaries developed by participating APRNs has led to the development and continued refinement of the Model’s nine core components. These core components consist of: screening; staffing; maintaining relationships; engaging patients and family caregivers; assessing and managing risks and symptoms; educating and promoting self-management; collaborating; promoting continuity; and fostering coordination. While each element is separately defined, it is important to note that all are interconnected and part of a holistic care process. Each of the TCM’s core elements is identified in Table 1 and described below and detailed on TCM website (Transitional Care Model, 2014).

Table 1. Transitional Care Model (TCM) Components and Definitions




Targets adults transitioning from hospital to home who are at high risk for poor outcomes.


Uses APRNs who assume primary responsibility for care management throughout episodes of acute illness.

Maintaining Relationships

Establishes and maintains a trusting relationship with the patient and family caregivers involved in the patients’ care.

Engaging Patients and Caregivers

Engages older adults in design and implementation of the plan of care aligned with their preferences, values and goals.

Assessing/ Managing Risks and Symptoms

Identifies and addresses the patient's priority risk factors and symptoms.

Educating/ Promoting Self-Management

Prepares older adults and family caregivers to identify and respond quickly to worsening symptoms.


Promotes consensus on plan of care between older adults and members of the care team.

Promoting Continuity

Prevents breakdowns in care from hospital to home by having same clinician involved across these sites.

Fostering Coordination

Promotes communication and connections between healthcare and community-based practitioners.


Identifying and targeting the specific population of older adults at risk for poor outcomes is the first essential component of the TCM. This may include hospitalized older adults with specific diagnoses known to have higher than average hospitalization risks, such as patients with heart failure or pneumonia (De Alba & Amin, 2014; Desai & Stevenson, 2012), or hospitalizations or emergency department (ED) visits in the prior 30 days (Garrison, Mansukhani, & Bohn, 2013). Key evidence-based risk factors used to screen patients who would benefit from the TCM have been identified by the University of Pennsylvania team and reinforced by other scholars. These risk factors include:

Other risk variables to consider are: patient age (e.g., 80 and older; McCauley, Bixby, & Naylor, 2006; Morandi et al., 2013); challenges in health literacy (Bailey et al., 2015; Baker et al., 2002; Baker, Parker, Williams, & Clark, 1998); language barriers (Gilbert, 2015; Karliner et al., 2012); and inadequate support system (Garrison et al., 2013; Ottenbacher et al., 2012).


APRNs also maintain responsibility for day-to-day delivery of transitional care services, including oversight of other transitional care team members. The TCM has been tested using master’s prepared APRNs who assume primary responsibility for care management of the older adult throughout episodes of acute illness. These APRNs provide patient-centered, comprehensive, holistic care that is culturally sensitive to the individualized needs of patients and their family caregivers (Bradway et al., 2012). APRNs also maintain responsibility for day-to-day delivery of transitional care services, including oversight of other transitional care team members.

APRNs are prepared to use the model with a multimodal approach. First, each APRN completes a four week live TCM webinar series (TCM, 2014). Typically the training also includes preparation in administration of patient screening and assessment tools and conducting interviews with patients and family caregivers. In addition, the webinar content is supplemented with one-on-one discussions about applying patient engagement strategies, learning how to present cases to the team, and participating in clinical rounds focused on issues commonly experienced by this population (e.g., heart failure, diabetes, chronic obstructive pulmonary disease, geriatrics, palliative and hospice care, home care, community-based care, managing MCCs).

Maintaining Relationships

A key feature of the TCM is establishing and maintaining trusting relationships with patients and family caregivers. A key feature of the TCM is establishing and maintaining trusting relationships with patients and family caregivers. Providers cultivate relationships through an evidence-based pattern of in-person visits and telephone calls. The seven-day per week availability of a consistent APRN further strengthens the development of relationships. In addition, the APRN prepares and accompanies each patient and family caregiver(s) to the first visit following the index hospital discharge, to establish collaborative relationships with community-based clinicians and model how patients can maximize time-limited visits and advocate to meet current and future care needs (Toles, Abbott, Hirschman, & Naylor, 2012). In addition to relationships with patients and family caregivers, APRNs also work to build trust with involved health and community-based team members and facilitate effective communication between patients, family caregivers, and their care team. This multidisciplinary approach recognizes all team members as partners in a care process focused on unique needs of patients and their family caregivers.

Engaging Patients and Family Caregivers

Engagement of older adults and their family caregivers in development and implementation of plans of care is an essential TCM component (Levine, Halper, Peist, & Gould, 2010; Naylor, Hirschman, O'Connor, Barg, & Pauly, 2013). APRNs work closely with patients and family caregivers to design care plans aligned with preferences, values, and goals, and to facilitate implementation of therapies and strategies to achieve patient and family caregiver goals. This requires extensive interactions between APRNs, patients, and family caregivers that begin with tools to measure engagement and activation; involvement of entire care team; identification; documentation; and update of patients’ health goals. Also important is inclusion of patients and family caregivers in team meetings and documentation and periodic updates of care plans (United Hospital Fund, 2014).

Scales such as the Patient Activation Measure (PAM) or Goal Attainment Scaling (GAS) may be useful to engage patients and family caregivers. Scales such as the Patient Activation Measure (PAM) or Goal Attainment Scaling (GAS) may be useful to engage patients and family caregivers (Hibbard, Stockard, Mahoney, & Tusler, 2004; Kiresuk, Smith, & Cardillo, 1994). APRNs respect patient autonomy while simultaneously encouraging incremental and necessary health behavioral changes to optimize health and quality of life. Finally, as part of the patient engagement process, advanced care plans are developed, documented, and shared with the care team members to ensure clarity and understanding about older adults’ preferences for care.

Assessing and Managing Risks and Symptoms

During initial meetings with patients, APRNs conduct comprehensive assessments of the unique symptoms experienced by each older adult (e.g., pain, shortness of breath, fatigue) as well as risk factors for poor outcomes (e.g., language barriers). For older adults with MCCs, this risk and symptom oriented approach relies on a consistent set of valid and reliable instruments, and has been found most effective to identify and prioritize needs. Common domains included in the comprehensive assessment include:

Depending on patient medical history, other domains assessed also may include:

Table 2 lists tools that have been tested in prior TCM research and are commonly used at settings that have adopted or adapted the TCM. Subsequent assessments are modified to focus on these priority issues.

Table 2. Domains and Examples of Standardized Tools Used for Clinical Assessment over Time



Completed with:


Six Item Screener (Callahan et al., 2002)



Confusion Assessment Method Diagnostic Algorithm (CAM) (Inouye et al., 1990) or Family CAM (FAM-CAM) (Steis et al., 2012)

Patient, Family CG


Timed Up and Go (Shumway-Cook et al., 2000)

Basic activities of daily living (Katz & Akpom, 1976)

Instrumental activities of daily living (Lawton & Brody, 1969)



Symptom Bother Scale (Heidrich & D'Amico, 1993)

Edmonton Symptom Assessment Scale-Pain and Anxiety (Bruera et al., 1991; Selby et al., 2010; Vignaroli et al., 2006)

Patient Health Questionnaire (PHQ-9) (Kroenke & Spitzer, 2002; Kroenke et al., 2001)


Patient engagement

Health Care Empowerment Inventory (HCEI) (Johnson, Rose, Dilworth, & Neilands, 2012)


Family CG

Care preferences

Absence or presence of advance directive

- Type of advance directive (e.g., Living Will, POLST, DPOAHC)

- Interest in discussing care

- Preferences if not documented


Family CG,


Health literacy

Brief Health Literacy Scale (BHLS) (Sand-Jecklin & Coyle, 2014; Wallston et al., 2014)


Family CG

Substance abuse

Alcohol Use Disorders Identification Test (AUDIT-C) cut-point of ≥5 risky alcohol use in geriatric population (Babor et al., 2001; Draper et al., 2015)


Polypharmacy & medication behavior

Number of medications taken daily or schedule complexity

High-risk medications




Verify self-monitoring being completed by Patient as part of self-management

- watch patient do what they need to for self-care (e.g., checking blood glucose, weighing self, checking blood pressure)

- this should consistently go in the SOAP note


Family CG


Unexplained weight loss of ≥10 pounds or ≥ 5% of body weight or persistent weight loss

Mini Nutrition Assessment (MNA) (Kaiser et al., 2009)



Family CG

Skin integrity

Braden Scale for Predicting Pressure Sore Risk (Braden, 2012; Braden & Bergstrom, 1989)


Family CG

Social support

Living situation

Availability of caregivers

Community resources used



Caregiver needs

Next Step in Care Assessment - guided conversation (United Hospital Fund, 2014)

- Availability, Training Needs, Worries

Family CG

Note: Some tools above are also collected consistently from all enrollees (intervention and comparison).
Key: EMR=Electronic Medical Record; CG=caregiver; POLST=Physician Orders for Life-Sustaining Treatment; DPOAHC=Durable Power of Attorney for Health Care; SOAP=subjective, objective, assessment, and plan.

For common symptoms or risks, a set of evidence-based decision responses are available for use by APRNs. For common symptoms or risks, a set of evidence-based decision responses are available for use by APRNs. For example, valid and reliable tools that prevent delirium or falls or more effectively manage pain may be core elements of plans of care. In general, APRN application of effective palliative care strategies, modified to respond to unique patient issues, is common. For complex symptom management, plans of care also may include consultation with palliative care specialists.

Educating/Promoting Self-Management

APRNs work with each older adult and their family caregivers to monitor and respond quickly to worsening symptoms. To further assist patients and family caregivers to understand early symptom recognition, providers consistently ask them to identify factors that contribute to exacerbations of chronic conditions (McCauley et al., 2006). Guided by individual patient goals and unique learning styles and preferences, the APRNs utilize multiple teaching strategies and tools, including coaching, modeling and the use of teach-back (Ditewig, Blok, Havers, & van Veenendaal, 2010; Haynes, Ackloo, Sahota, McDonald, & Yao, 2008).

Guided by individual patient goals and unique learning styles and preferences, the APRNs utilize multiple teaching strategies and tools... Plans for patient and family caregiver learning are developed in collaboration with the whole team, integrated into the entire care plan, and implemented and reassessed over multiple encounters. Patient and family caregivers are provided a written plan for urgent and emergent situations that includes appropriate clinician or provider contact information. A personal health record also is provided and periodically updated. The promotion of healthy behaviors is consistently addressed in the care plan and may include strategies to increase exercise, make appropriate food choices, and obtain preventive care (e.g., immunizations; Nicholas & Hall, 2011; Spalding & Sebesta, 2008).

Medication management is an integral component of the care plan (Curry, Walker, Hogstel, & Burns, 2005). Promoting both older adults’ and family caregivers’ understanding of the need for and appropriate administration of medications is central to effective management. The APRN reviews prescription and over-the-counter medications with each patient and their family caregivers. Reminder or dose organization systems, plans for obtaining refills, and access to community-services to assist with managing co-pays also are common strategies used to foster adherence.

Promoting emotional health is essential for encouraging behavioral change. The APRN collaborates with the entire team to identify and fortify sources of emotional support, including community based organizations, peer groups, and the inclusion of family and friends.


Use of health information technology... may greatly facilitate collaboration. APRNs encourage consensus about plans of care among older adults, family caregivers, and members of the care team. Outreach to all involved physicians (e.g., primary care, specialists, hospitalists) and other team members in various settings (e.g., nurses, social workers, pharmacists physical therapists, staff in skilled nursing facilities and community-based organizations) is important to achieve shared understanding of patient goals and care plans. Use of health information technology, including electronic health records (EHRs) and secure email systems, may greatly facilitate collaboration. While requiring substantial up-front investment, this multidisciplinary approach streamlines plans of care, decreases burden on patients and family caregivers to coordinate care and contributes to enhanced outcomes (Cowan et al., 2006).

Promoting Continuity

Between in-person visits, APRNs contact patients by phone and they are available by telephone seven days a week. The TCM is designed to prevent breakdowns in care across settings (e.g., hospital to home) by having the same clinician deliver and coordinate the intervention throughout the entire care episode. Each APRN begins to work with the patient, family caregivers, and care team at hospital admission; the same APRN implements the plan of care in the skilled nursing facility (SNF), if referred, or in the patient home, substituting for traditional skilled care provided by nurses. APRNs visit their patients within 24 hours of hospitalization, daily throughout the hospitalization, within 24 hours following hospital discharge to SNF or patient home, and at least weekly throughout the first month. Subsequently, APRNs visit patients at least bi-weekly. Between in-person visits, APRNs contact patients by phone and they are available by telephone seven days a week. Typically, this initial phase of intervention occurs over a two month period (range one to three months). As noted earlier, the research team is currently assessing the effects of longer-term follow-up on the care and outcomes of older adults with MCCs.

Fostering Coordination

APRNs promote communication and connections between hospital, post-acute, and community-based staff members, including facilitating transfer of essential information (Hirschman et al., 2015). APRNs identify formal and informal services received prior to hospitalizations and determine need for continuation of services following patient transition(s) to home. APRNs are responsible for referrals for new health and/or community based services, as well as monitoring to assure that patients receive high value needed services in a timely manner (Low, Yap, & Brodaty, 2011; Tappenden, Campbell, Rawdin, Wong, & Kalita, 2012). In collaboration with patients, family caregivers, and other team members, APRNs may also identify additional appropriate services, such as palliative or hospice care, and work with patients to ensure seamless transitions to such programs.

Measuring TCM’s Core Components and the Overall Model Effects

Core Components

Consistent measurement of the application of the TCM core components and the effects of this evidence-based care management approach on patient reported outcomes, resource use, and costs is essential to assure successful implementation and continued performance improvement and sustainability. Standard tools have been constructed to assess cross-cutting metrics, such as adherence to contact pattern (e.g., visit within 24 hours of enrollment, seven days per week telephone availability). Additionally, our research team has established metrics to benchmark adherence to each TCM core component. The use of a consistent clinician who both designs the transitional care plan while the patient is hospitalized and implements the plan following discharge is an example of a measure used to assess adherence to “Promoting Continuity.”

Some model users have chosen to adapt one or more core components to reflect local customs and practices. Others may not have resources (e.g., EHRs) to apply the TCM components. The University of Pennsylvania team recognizes that, while some healthcare settings and communities choose to adopt the TCM core components as described above, multiple factors may affect how other sites implement this evidence-based care management approach. Some TCM users have chosen to adapt one or more core components to reflect local customs and practices. Others may not have resources (e.g., EHRs) to apply the TCM components. An ongoing study, Local Adaptations of the Transitional Care Model (Grant No. 71753) funded by the Robert Wood Johnson Foundation, is helping our team to identify how health systems and communities throughout the United States are adapting common core components. The University of Pennsylvania team members hypothesize that some adaptations may further advance the model’s benefits, extending its reach and further improving outcomes. The team also hypothesizes that the nature and extent of some adaptations may substantially reduce or eliminate the TCM’s demonstrated benefits.


Measuring changes over time in key outcome domains... is important to benchmark evidence of the impact of the TCM and continually improve performance. Key patient and family caregiver outcomes have been used to assess the effectiveness of the TCM both in past research and in the implementation of the model in multiple health systems and communities. Measuring changes over time in key outcome domains such as patient symptoms, functional status (e.g., cognitive, physical, emotional), and quality of life, as well as family caregiver outcomes such as burden, is important to benchmark evidence of the impact of the TCM and continually improve performance (See Table 2). Assessing patient, family caregiver, and collaborating clinician perspectives about the model (e.g., overall experience with care and specific dimensions such as care continuity) provides additional important dimensions of the TCMs’ perceived value. Changes in resource use (e.g., time to first rehospitalization, total number of all-cause hospitalizations, total number of days hospitalized) are central to promoting support for the investment in TCM. Both the cost to implement the program (e.g., time devoted by APRNs to implement transitional care services) as well as costs avoided (e.g., number of ED visits or rehospitalizations prevented), are valuable data to demonstrate the TCM’s effects.


Currently, the team is examining the potential of the TCM to add value to emerging care delivery models including PCMHs, accountable care organizations, community-based palliative care programs and population health models. The core components of the TCM described above are the product of years of rigorous, multidisciplinary efforts to generate and translate research. The University of Pennsylvania team has greatly benefited from the partnership of multiple funders, health systems, payers, purchasers, and nationally recognized leaders in health system. Most importantly, thousands of chronically ill older adults and their family caregivers have collectively contributed to the refinement of all elements of this care management strategy, as well as measures used to assess the model’s impact. Widely disseminated, the TCM (2014) has been recognized as a top-tiered, evidence based approach that, if scaled, could have a major positive effect on the population of Medicare beneficiaries transitioning from hospital to home (Coalition for Evidence-Based Policy, 2010).

Currently, the team is examining the potential of the TCM to add value to emerging care delivery models including PCMHs, accountable care organizations, community-based palliative care programs and population health models. Additionally, we are testing the model with expanded patient populations (e.g., patients with cancer). Finally, a central focus of the team’s current efforts is a rigorous examination of adaptations of the TCM by local health systems and communities throughout the United States, with the goal of understanding how such adaptations may extend the reach and improve the benefits derived from this evidence-based strategy. The research team’s ongoing efforts to expand the TCM to all settings where older adults receive care, and examine how local settings are adapting the model, represent important next steps to assure that chronically ill older adults and their family caregivers have increased access to the evidence-based care management that this population needs and deserves.


Karen B. Hirschman, PhD, MSW

Karen B. Hirschman is the NewCourtland Term Chair in Health Transitions Research and a Research Associate Professor at the University of Pennsylvania School of Nursing in Philadelphia, PA.  Since 2004, she has been a member of the Transitional Dr. Hirschman is a member of the New Courtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, Philadelphia, PA. Care Model team lead by Dr. Mary Naylor.

Elizabeth Shaid, MSN, CRNP

Elizabeth Shaid is an advanced practice registered nurse at the University of Pennsylvania School of Nursing in Philadelphia, PA. She has over 20 years of clinical practice experience and runs the Transitional Care Model seminar course at the University of Pennsylvania School of Nursing.

Kathleen McCauley, PhD, RN, FAAN

Kathleen McCauley is the Class of 1965 25th Reunion Term Professor and a Professor of Cardiovascular Nursing at the University of Pennsylvania School of Nursing in Philadelphia, PA. She has been a member of the Transitional Care Model team as a clinical expert for over 20 years.

Mark V. Pauly, PhD

Mark V. Pauly is the Bendheim Professor, Professor of Health Care Management, and Professor of Business Economics and Public Policy at the Wharton School at the University of Pennsylvania in Philadelphia, PA. He has been the chief health economist for the Transitional Care Model for over 20 years.

Mary D. Naylor, PhD, RN, FAAN

Mary D. Naylor is the Marian S. Ware Professor of Gerontology at the University of Pennsylvania School of Nursing, Philadelphia, PA. Dr. Naylor is the Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing in Philadelphia, PA. She is the architect of the Transitional Care Model.


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© 2015 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2015

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