Transitional care helps ensure patients receive the best care during transfers within the hospital, moving from the hospital to another facility (such as a nursing home) and going home.

Older adult patients and their caregivers are often unprepared for transitions and overwhelmed by discharge information. There is also evidence that older adult patient safety is put at risk during transitions.

Innovative transitional care models address these problems. The APN transitional care model and the Care Transitions Intervention model are two examples.

  • APN Transitional Care Model

    This model involves advanced practiced nurses (APNs) who manage patients and coordinate the transition.

  • Care Transitions Intervention Model

    This model involves a specialized nurse, or “transition coach,” who teaches patients self-management skills and ensures their needs are met during transition.

    The transition coach helps:
    • Manage the older adult patient’s medications
    • Maintain patient health records
    • Complete follow-up care with their primary physician
    • Recognize and respond when the patient’s condition is worsening


Transitions Links:

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