For Nurses and Advanced Practice

Smoothing the transition from hospital to home

Penn's Transitional Care Model (TCM) addresses the cyclical problem of unplanned readmissions for the growing number of patients coping with complex chronic conditions. TCM measurably improves health outcomes, enhances patient satisfaction and reduces both hospital readmission rates and total health care costs, compared with standard care.

How the Transitional Care Model Works

Many elderly patients discharged from hospitals neglect to receive recommended follow-up outpatient care. It can be complicated for elderly patients to navigate their care through primary care physicians, specialists, other care providers and multiple medications. In the Transitional Care Model, a nurse visits the patient in the hospital and forms an ongoing relationship. As a nurse bonds with their patient, it helps to put the patient's mind at ease, knowing that this person will be visiting their home and assisting them with medical care. In addition to coordinating services and facilitating communication among the patient, family, informal caregivers and health care professionals, nurses are ready to treat the patient at home to prevent minor problems from escalating and necessitating readmission.

The services implemented by the Transitional Care Model include:

  • Visiting high-risk elderly patients daily in the hospital to streamline their plans of care, and design and coordinate inpatient care
  • Assessing patients' health goals and needs
  • Designing a collaborative, evidence-based transitional care plan for when patients leave the hospital
  • Visiting or, later, phoning patients at home regularly after discharge
  • Educating patients and caregivers about symptom management and accessing needed community and social services
  • Advocating for patients with multiple care providers to obtain services and equipment
  • Continually reassessing the patient's status with the patient themselves, caregivers and primary care providers
  • Being available by phone seven days a week

Recently, Penn Medicine launched a nurse-led program to identify patients at risk for readmissions while still hospitalized and linking them with a specialty nurse called a Care Connector. This new program was piloted with heart failure patients and now has expanded to include primary care patients affiliated with select regional medical home programs. Currently there is a Care Connector RN based at each hospital in the health system.

Share This Page: