Transitional care nursing helps connect care as a person moves between settings or teams. The work has a beginning, a period of support and a planned transfer into continuing care.
Penn Nursing describes transitional care as time-limited services intended to support continuity across settings and levels of care. Its nursing-led Transitional Care Model is a specific approach developed at the University of Pennsylvania. The model's name should not be used as a label for any isolated discharge call.
Define the service being offered
A team introducing transitional care should describe its actual program. Which patients are offered support? When does responsibility begin? Which clinician can respond to a new concern? What contact methods are available? How is responsibility handed to the continuing care team?
These questions are a proposed service-design checklist. They make the program understandable to patients and staff without promising a level of coverage the organization does not provide.
For a named model, use its implementation resources and training. Penn's practice resources describe interdisciplinary leadership, communication about workflows, documentation and monitoring tools. Adapting a program requires explaining the changes, rather than assuming the original model's results automatically apply.
Connect several tasks across the transition
AHRQ's Re-Engineered Discharge toolkit provides another structured approach. Its components include arranging follow-up, tracking pending results, organizing services and equipment, reconciling medicines, providing understandable instructions, transmitting the discharge summary and making a follow-up call. It illustrates how transition support involves connected activities before and after discharge.
For nursing teams, a useful working record separates each identified need from its status and owner. A request sent to another service is different from an accepted request, and an accepted request is different from a completed visit.
Make the handover measurable
Consider a fictional patient whose hospital discharge plan includes a specialist appointment and home support. The transition nurse learns that the appointment is booked, but the patient has not heard from the home service.
The remaining task is specific: establish whether the service accepted the referral, clarify the start arrangements and report the answer to the patient and continuing team. Repeating the appointment instructions would not resolve that gap.
Track the next action and review date according to the program's process. When a concern needs clinical evaluation, use the appropriate clinical escalation route.
End support deliberately
Before closing a transition episode, review which goals were addressed, what remains unresolved and who has accepted responsibility for continuing work. Give the patient a clear contact route for the next stage.
Evaluate the program using more than the number of calls made. A suggested local review might examine completed handovers, unresolved service needs and the patient's account of whether the plan was workable. Choose definitions before comparing results over time.
The broader practice of transitional care, Penn's named model and Medicare's transitional care management billing service are distinct concepts. Billing details and follow-up timing are discussed in follow-up after hospital discharge. See also discharge planning and care plans across organizations.
Sources
- Transitional Care Model (accessed 2026-09-17) — Penn Nursing.
- TCM in Practice (accessed 2026-09-17) — Penn Nursing.
- Re-Engineered Discharge Toolkit: Overview (accessed 2026-09-17) — AHRQ.