This case study will discuss the core components of the Transitional Care Model (TCM) and demonstrate the translation of them into clinical practice. It will also identify gaps in current clinical knowledge related to management of high risk chronically ill adults. In completion of this case study, learners will be able to integrate knowledge of the TCM Model into state of the science management of common chronic health problems to develop plans of care that manages the transition of these high risk elderly from hospital to home, including temporary stay in rehabilitation or skilled nursing facility.

The American Association of Colleges of Nursing (AACN) and the Hartford Institute for Geriatric Nursing at New York University College of Nursing (HIGN), with generous funding from the John A. Hartford Foundation, developed these case studies to facilitate the transition to Adult-Gerontology APRN education as described in The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification and Education. One of the major goals of this project is to provide Primary and Acute Care Adult NP faculty, Adult CNS faculty, and other faculty who prepare NPs or CNSs to care for older adults, (e.g. FNPs, WHNPs, Women’s Health CNSs), with multiple resources and strategies to assist them in making this transition.