Scaling up: bringing the transitional care model into the mainstream

Issue Brief (Commonw Fund). 2010 Nov;103:1-12.


Elderly, chronically ill people experience frequent changes in health status that require transitions among health care providers and settings. This issue brief describes two projects that identified the essential elements of effective care management interventions for this population and the facilitators of translating one such intervention, the Transitional Care Model (TCM), into mainstream practice. Together these projects demonstrate that successful translation of the TCM, which incorporates both in-person contact and a nurse-led, interdisciplinary team approach, can effectively interrupt patterns of frequent rehospitalizations, reduce costs, and improve patient health status. Findings from these projects inform challenges that must be overcome to facilitate the translation of effective care management innovations into mainstream practice.

MeSH terms

  • Aged
  • Caregivers / education
  • Chronic Disease / nursing*
  • Chronic Disease / therapy
  • Continuity of Patient Care / organization & administration*
  • Critical Care / organization & administration*
  • Health Services for the Aged / organization & administration*
  • Home Care Services / organization & administration*
  • Humans
  • Insurance Coverage
  • Insurance, Health
  • Medicare
  • Patient Care Management / organization & administration*
  • Patient Care Team
  • Patient Discharge
  • Patient Education as Topic
  • Patient Participation
  • Patient Transfer / organization & administration*
  • Professional-Patient Relations
  • United States