title: Continuity of Care: The Transitional Care Model.
abstract: 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.
authors.forename: Karen B
authors.initials: KB
authors.lastname: Hirschman
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Shaid
authors.forename: Kathleen
authors.initials: K
authors.lastname: McCauley
authors.forename: Mark V
authors.initials: MV
authors.lastname: Pauly
authors.forename: Mary D
authors.initials: MD
authors.lastname: Naylor
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D019090:Case Management; D055318:Evidence-Based Nursing; D006760:Hospitalization / Q000191:economics; D006801:Humans; D016294:Models, Nursing; D009730:Nursing Assessment / Q000379:methods*; D010043:Outcome and Process Assessment, Health Care; D010360:Patient Transfer / Q000191:economics / Q000379:methods*; D012307:Risk Factors