Transitional Care Model

The Transitional Care Model (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions. TCM emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management all accomplished with the active engagement of patients and their family, informal caregivers and in collaboration with the patient's physicians.

A summary of the TCM gives an overview of the model.