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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). 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 Among the more than 20 million Medicare beneficiaries, 37% have five or more chronic conditions (Centers for Medicare & Medicaid Services [CMS], 2012).

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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.

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). 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). In a Medicare Payment Advisory Commission (Med PAC) 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 (Med PAC, 2015). However, among Medicare beneficiaries with four or more MCCs, the 30-day rehospitalization rate was 36% (Lochner, Goodman, Posner, & Parekh, 2013). Advancing high value transitional care: The central role of nursing and its leadership.

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