28^th World Nursing & Nurse Practitioner Conference

Transitional Nursing Care

The Transitional Care Model is designed to prevent health complications and rehospitalisation of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up, coordinated by a master’s-level “Transitional Care Nurse” who is trained in the care of people with chronic conditions.  At the time of hospitalization, the Nurse: (i) conducts a comprehensive assessment of the patient’s health status, health behaviours, level of social support, and goals; (ii) develops an individualized plan of care consistent with evidence-based guidelines, in collaboration with the patient and her doctors; and (iii) conducts daily patient visits, focused on optimizing patient health at discharge.