The transitional care model (TCM): hospital discharge screening criteria for high risk older adults.

WHY: Older adults hospitalized for a newly diagnosed acute condition or an exacerbation of a chronic condition are at heightened risk of rehospitalization due to poorly managed transitions from hospital to home or other care setting. For older patients with multiple chronic conditions this “hand-off” period takes on even greater importance. One-quarter to one-third of older adults with multiple chronic conditions are re-hospitalized due to preventable complications (Lochner et al., 2013). This evidence-based practice approach addresses needed hospital assessment and transition planning that should be completed by registered nurses or advanced practice nurses in managing the complex care of hospitalized older adults.