Continuity of Care: The Transitional Care Model

TLDR

Older adults with multiple chronic conditions and additional risk factors face significant challenges in managing care, especially during acute illness, and the Transitional Care Model has been rigorously tested to address these needs while reducing costs. The article aims to summarize the evidence base, core components, and impact of the Transitional Care Model to identify effective strategies for improving care transitions and outcomes in older adults with complex chronic conditions. The Transitional Care Model is a nurse‑led intervention that targets older adults at risk during transitions across settings, comprising nine core components that are measured to assess its impact.

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.