Seniors living with multiple chronic conditions face complications in the form of social barriers, deficits in activities, and episodes of acute illness. This makes it very difficult for them to manage these challenges on their own.

Therefore, continuity of care while transitioning between various care facilities becomes indispensable for chronic disease patients. The transitional care model (TCM) has been rigorously tested and has demonstrated effectiveness in improving care quality and reducing healthcare costs.

This health intervention is aimed at improving the health outcomes for seniors and older adults as they move between clinicians and across healthcare settings. In this blog post, we aim to educate the seniors and their caregivers on the critical components of TCM.

1. Screening

This component identifies the most vulnerable population group that would benefit from a transitional care model. Most seniors with specific diagnoses such as COPD and hypertension have a greater than average hospitalization rate.
Patients who have a history of depression, anxiety, and cognitive impairment can benefit from TCM. Age is another risk factor that makes people vulnerable to chronic diseases.

2. Maintaining Relationships

According to the Centers for Medicare & Medicaid Services (CMS), over 20 million Medicare beneficiaries have five or more chronic diseases. The transitional care model targets not only millions of patients but also their family givers.

This component aims at building trusting relationships with family caregivers as well as patients. It is achieved through regular telephone calls and in-person visits to maximize time-limited visits.

3. Engaging Patients and Caregivers

Creating a detailed care plan is just one part of TCM. Engaging patients and caregivers are necessary for its effective implementation. They work closely with care providers to devise a plan that aligns with their goals, values, and preferences.

It demands extensive communication between patients, care specialists, and family caregivers to achieve the health goals.

4. Managing Risks and Symptoms

Doctors and care providers screen the patients for unique symptoms during initial meetings. Symptoms can be fatigue, shortness of breath, pain, etc. They also identify the risk factors such as language barriers that could lead to poor outcomes.

Patients are scanned for mental health, physical symptoms, quality of life, family caregiver needs, and overall functional status.

5. Promoting Self-Management

Not every chronic disease patient has a family caregiver nearby. For this reason, self-management is critical, and it begins with educating the patient about their condition.
Enhancing life quality requires them to be more independent and proactive, which is only possible through self-care. Hence, the transitional care model takes into account the unique learning preferences and style of each patient.

6. Collaborating

TCM encourages consensus about the care plan among family caregivers, seniors, and other patient care team members. It also involves outreach to primary care specialists, nurses, therapists, pharmacists, and social workers.

They should have a shared understanding of the care plan and patient goals. The use of secure email systems and electronic health records (EHRs) facilitate collaboration.

7. Maintaining Continuity

Breakdowns in care are the main reason why TCM was designed. During the entire care episode, the same care team should coordinate the intervention to serve this primary purpose. Within 24 hours of hospitalization, the team should visit the patient.

From hospitalization to discharge, the team stays in touch with the patient. Once the senior is discharged, the assigned care team follows-up for at least a month or two.

8. Fostering Coordination

The transitional care model facilitates coordination between community-based staff members, post-acute team, and hospital staff. This includes the transfer of crucial information. It is necessary to ensure continuity of care.

The care providers also provide referrals for a new community or health-based services. They monitor the patient every day to ensure timely intervention when a health emergency strikes. Besides, they may also recommend palliative care in collaboration with family caregivers and patients.


The transitional care model focuses on reducing healthcare costs, enhancing patient outcomes, and improving chronically ill patients’ care. A multidisciplinary team of care specialists works towards identifying health goals and implementing a comprehensive care plan.

At AdvantagePlusNurses, a professional care team is assigned to manage transitions of care for seniors. They ensure that patients never miss an appointment and stick to their treatment schedule. We have been able to reduce the hospitalization rate with TCM significantly.

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