Issue 26: The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults.
Try This:® a publication of the Hartford Institute for Geriatric Nursing, is a series of assessment tools and best practice approaches to care where each issue focuses on a topic specific to the older adult population.
"The Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults" authored by M. Brian Bixby and Mary D. Naylor from the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, describes how to identify patients at high risk for poor outcomes after hospitalization for an acute or exacerbated chronic illness.
This best practice approach to care highlights those screening criteria, that if positive, should trigger the nurse to implement post-discharge interventions to assure appropriate information transfer and follow-up after discharge to home or other care setting.
http://consultgerirn.org/uploads/File/trythis/issue26.pdf?
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