The Transitional Care Model (TCM) is a nurse coordinated, team-based care model proven in multiple NIH funded clinical trials to improve the health outcomes of older adults coping with complex care needs while reducing health care costs.

Check out the latest Transitional Care Model courses offered at Penn. Self-paced and fully online, a 2-hour introductory course and a comprehensive 25-hour course are available.

Advancing High Quality Care: The Transitional Care Model

Brief 2-hour course | ENROLL NOW

Managing transitions in care, especially among older adult patients, enhances the patient experience, improves health and quality-of-life outcomes, and reduces use of costly services. Transitional care includes a range of time-limited services designed to ensure health care continuity and prevent poor outcomes among at-risk populations as they move from one level of care to another, among multiple health care team members, and across settings, such as hospitals to homes. In this course, you will learn about the research, policy, and practice implications of the Transitional Care Model—an evidence-based program of care designed to meet the needs of at-risk older adults in transition.

This introduction to the Transitional Care Model is achieved through an online, self-paced, two-hour course. Learners may start the course at any time and move through the course material at any speed they choose. Upon completing this course, learners will earn continuing education credit that may be applied to their current healthcare licensure requirements. 

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Foundations in Transitional Care: The Transitional Care Model

Comprehensive 25-hour course | ENROLL NOW

Penn Nursing is proud to offer an open online course designed for nurses, especially advanced practice registered nurses, and other health care professionals seeking to improve care systems by implementing the Transitional Care Model (TCM). The TCM is a nurse coordinated, team-based care model proven in multiple NIH funded clinical trials to improve the health outcomes of older adults coping with complex care needs while reducing health care costs.

Christina Whitehouse, PHD, CRNP, a TCM clinical expert, is featured throughout the course, working with a patient and their family caregiver as a team to address their immediate and longer-term health and wellness goals.In this course, students learn about the research, policy, and practice implications of this model of care. This unparalleled educational opportunity enables participants to engage in a world-wide community of like-minded innovators and to learn how to deliver high quality care that can enhance patient experiences, improve outcomes and make better use of limited resources.

In this self-paced online format, participants are able to engage in knowledge and skill building whenever and wherever they want. This course takes approximately 25 hours to complete and uses multiple approaches to learning including video vignettes, video lectures, readings, and case studies based on information gleaned from studies of the TCM and other evidence-based transitional care approaches.

Course participants will gain an understanding of risk factors that commonly affect at-risk patient populations as well as specific strategies, tools and techniques to assess patients’ priority needs, identify and help meet patients’ health goals and prevent future acute health problems. At the completion of the course, participants will have a comprehensive knowledge of delivering services consistent with the TCM.

An emphasis is placed on lessons learned in the application of the TCM over two decades, including:

• engaging older adults and family caregivers as team members,
• fostering advanced care planning,
• promoting shared decision-making and adherence,
• measuring patients’ progress and,
• fostering continuous improvement. 

The course is graded on a pass/fail basis. Students who pass the course will receive 25 continuing education units from the Pennsylvania State Nurses Association, an accredited approver designated by the American Nurses Credentialing Center’s Commission on Accreditation (Approval # 124-3-H-15). All students who pass the course will also receive a Certificate of Completion.