Reducing Rehospitalization: The Transitional Care Model

1.0 CEU

This course is designed to broadly educate nurses, social workers and other providers about care transitions theory and the usefulness of the Transitional Care Model (TCM) in meeting the needs of patients and family caregivers making the transition from an acute care hospitalization to their home, a rehabilitation or skilled nursing facility.

This course covers:

  • Integrating patients’ health goals into self-motivated, patient-specific care.
  • Avoiding emergency room transfer or preventing readmissions through provision of evidence-based care.
  • Trends in patient and family caregiver support and education.
  • Strategies for helping patients and family caregivers manage when end-of-life care becomes a priority.

 Course Objectives:

  • Define transitional care and integrate core components of the Transitional Care Model into their clinical practice.
  • Identify patients’ goals for their healthcare and integrate these goals into discussions of what patient-specific care means.
  • Identify strategies and resources to support physical and emotional health into a plan to support patient and family caregiver’s competency in care management.
  • Discuss strategies for helping patients and family caregivers manage care when end-of-life care becomes a priority.

Course Approvals:

  • NAB: This program has been approved for Continuing Education for 1.0 total participant hours by NAB/NCERS – approval# 20191114-1-A48150-DL – expires 11-14-2019.
  • CE Broker Approved for Florida Long Term Care Administrators, Nurses, and Certified Nurse Aides as well as District of Columbia Certified Nurse Aides and Home Health Aides
  • Oregon Board of Examiners of Nursing Home Administrators
  • Kansas Department of Health and Environment: Approval #: LTS -A1138 (Resident Care)

About the Instructor

brian-bixbyBrian Bixby is an Advanced Practice Nurse with the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing since 1998 testing the applicability of the Transitional Care Model (TCM) with diverse populations including those with heart failure, physical disabilities and cognitive impairment. A nurse since 1986, Brian has extensive clinical experience in acute care, interventional cardiology and electrophysiology. Currently he is Clinical Associate for TCM translational efforts within the University of Pennsylvania Health System and Course Coordinator for Penn’s TCM training course. He has presented nationally and published on the role of the APN in meeting transitional needs.