Advancing High Value Transitional Care

The Central Role of Nursing and Its Leadership

Abstract

Addressing the health care needs of older adults coping with multiple conditions and their family caregivers in a person- and family-centered, safe, effective, efficient, equitable, and timely manner will be a major issue confronting America's health care system for the foreseeable future. This article describes the efforts of a multidisciplinary team to create a path from system fragmentation to integration for this vulnerable population through the design, testing, and translation of the Transitional Care Model (TCM). The TCM is a nurse-led, team-based care delivery system innovation that is designed to increase alignment of the care system with the preferences, needs, and values of high-risk individuals and their family caregivers and achieve higher-quality outcomes while reducing health care costs. A rigorous body of evidence reinforces a tremendous opportunity to address the urgent need for higher-value health care, through widespread implementation of the TCM for chronically ill older adults. Capitalizing on this opportunity will require the investment, commitment, and support of nursing and its leadership.