{"id":"https://openalex.org/W2409328652","doi":"https://doi.org/10.3912/ojin.vol20no03man01","title":"Continuity of Care: The Transitional Care Model","display_name":"Continuity of Care: The Transitional Care Model","publication_year":2015,"publication_date":"2015-09-30","ids":{"openalex":"https://openalex.org/W2409328652","doi":"https://doi.org/10.3912/ojin.vol20no03man01","mag":"2409328652","pmid":"https://pubmed.ncbi.nlm.nih.gov/26882510"},"language":"en","primary_location":{"id":"doi:10.3912/ojin.vol20no03man01","doi":"https://doi.org/10.3912/ojin.vol20no03man01","is_oa":true,"landing_page_url":"https://doi.org/10.3912/ojin.vol20no03man01","pdf_url":"http://www.partnershipforsolutions.org/DMS/files/MedBeneficiaries2-03.pdf","source":{"id":"https://openalex.org/S4210199930","display_name":"OJIN The Online Journal of Issues in Nursing","issn_l":"1091-3734","issn":["1091-3734"],"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["cwts-core","jufo-2","norway-1","poland-40"],"host_organization":null,"host_organization_name":null,"host_organization_lineage":[],"host_organization_lineage_names":[],"type":"journal"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"OJIN: The Online Journal of Issues in Nursing","raw_type":"journal-article"},"volume":null,"type":"article","is_traditional":true,"indexed_in":["crossref","pubmed"],"open_access":{"is_oa":true,"oa_status":"bronze","oa_url":"http://www.partnershipforsolutions.org/DMS/files/MedBeneficiaries2-03.pdf","any_repository_has_fulltext":false},"authorships":[{"author_position":"first","author":{"id":"https://openalex.org/A5002078656","display_name":"Karen B. Hirschman","orcid":"https://orcid.org/0000-0003-4886-7765","observed_orcids":["https://orcid.org/0000-0003-4886-7765"]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"Karen Hirschman","raw_affiliation_strings":[],"raw_orcid":null,"affiliations":[]},{"author_position":"middle","author":{"id":"https://openalex.org/A5091861734","display_name":"Elizabeth Shaid","orcid":"https://orcid.org/0000-0002-2282-7872","observed_orcids":["https://orcid.org/0000-0002-2282-7872"]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"Elizabeth Shaid","raw_affiliation_strings":[],"raw_orcid":null,"affiliations":[]},{"author_position":"middle","author":{"id":"https://openalex.org/A5006446828","display_name":"Kathleen M McCauley","orcid":null,"observed_orcids":[]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"Kathleen McCauley","raw_affiliation_strings":[],"raw_orcid":null,"affiliations":[]},{"author_position":"middle","author":{"id":"https://openalex.org/A5072048687","display_name":"Mark V. Pauly","orcid":"https://orcid.org/0000-0003-4957-4825","observed_orcids":["https://orcid.org/0000-0003-4957-4825"]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"Mark Pauly","raw_affiliation_strings":[],"raw_orcid":null,"affiliations":[]},{"author_position":"last","author":{"id":"https://openalex.org/A5034514941","display_name":"Mary Duffin Naylor","orcid":"https://orcid.org/0000-0001-9287-153X","observed_orcids":["https://orcid.org/0000-0001-9287-153X"]},"institutions":[],"countries":[],"is_corresponding":false,"raw_author_name":"Mary Naylor","raw_affiliation_strings":[],"raw_orcid":null,"affiliations":[]}],"institutions":[],"countries_distinct_count":0,"institutions_distinct_count":0,"corresponding_author_ids":[],"corresponding_institution_ids":[],"apc_list":null,"apc_paid":null,"fwci":13.8178,"has_fulltext":true,"cited_by_count":313,"citation_normalized_percentile":{"value":0.99370137,"is_in_top_1_percent":true,"is_in_top_10_percent":true},"cited_by_percentile_year":{"min":98,"max":100},"biblio":{"volume":"20","issue":"3","first_page":"1","last_page":"1"},"is_retracted":false,"is_paratext":false,"is_xpac":false,"primary_topic":{"id":"https://openalex.org/T12174","display_name":"Hospital Admissions and Outcomes","score":0.8467000126838684,"subfield":{"id":"https://openalex.org/subfields/2911","display_name":"Leadership and Management"},"field":{"id":"https://openalex.org/fields/29","display_name":"Nursing"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},"topics":[{"id":"https://openalex.org/T12174","display_name":"Hospital Admissions and Outcomes","score":0.8467000126838684,"subfield":{"id":"https://openalex.org/subfields/2911","display_name":"Leadership and Management"},"field":{"id":"https://openalex.org/fields/29","display_name":"Nursing"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T12246","display_name":"Chronic Disease Management Strategies","score":0.08900000154972076,"subfield":{"id":"https://openalex.org/subfields/2713","display_name":"Epidemiology"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T11376","display_name":"Geriatric Care and Nursing Homes","score":0.022099999710917473,"subfield":{"id":"https://openalex.org/subfields/2717","display_name":"Geriatrics and Gerontology"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}}],"keywords":[{"id":"https://openalex.org/keywords/transitional-care-model","display_name":"Transitional Care Model","score":0.996999979019165},{"id":"https://openalex.org/keywords/continuity-of-care","display_name":"continuity of care","score":0.8709999918937683},{"id":"https://openalex.org/keywords/care-transitions","display_name":"care transitions","score":0.8009999990463257},{"id":"https://openalex.org/keywords/older-adults","display_name":"older adults","score":0.984000027179718},{"id":"https://openalex.org/keywords/chronic-disease","display_name":"chronic disease","score":0.7329999804496765},{"id":"https://openalex.org/keywords/nurse-led-intervention","display_name":"nurse-led intervention","score":0.8659999966621399},{"id":"https://openalex.org/keywords/care-management","display_name":"care management","score":0.8270000219345093},{"id":"https://openalex.org/keywords/activities-of-daily-living","display_name":"activities of daily living","score":0.8730000257492065},{"id":"https://openalex.org/keywords/acute-illness","display_name":"acute illness","score":0.5630000233650208},{"id":"https://openalex.org/keywords/health-care-costs","display_name":"health care costs","score":0.8309999704360962},{"id":"https://openalex.org/keywords/evidence-based-practice","display_name":"evidence-based practice","score":0.5960000157356262}],"concepts":[{"id":"https://openalex.org/C2779685841","wikidata":"https://www.wikidata.org/wiki/Q7834462","display_name":"Transitional care","level":3,"score":0.8013510704040527},{"id":"https://openalex.org/C160735492","wikidata":"https://www.wikidata.org/wiki/Q31207","display_name":"Health care","level":2,"score":0.6469210386276245},{"id":"https://openalex.org/C2780665704","wikidata":"https://www.wikidata.org/wiki/Q959298","display_name":"Intervention (counseling)","level":2,"score":0.5509030222892761},{"id":"https://openalex.org/C2781385661","wikidata":"https://www.wikidata.org/wiki/Q4677918","display_name":"Acute care","level":3,"score":0.5266173481941223},{"id":"https://openalex.org/C71924100","wikidata":"https://www.wikidata.org/wiki/Q11190","display_name":"Medicine","level":0,"score":0.5163508653640747},{"id":"https://openalex.org/C2164484","wikidata":"https://www.wikidata.org/wiki/Q5170150","display_name":"Core (optical fiber)","level":2,"score":0.48216789960861206},{"id":"https://openalex.org/C159110408","wikidata":"https://www.wikidata.org/wiki/Q121176","display_name":"Nursing","level":1,"score":0.4689556956291199},{"id":"https://openalex.org/C2908647359","wikidata":"https://www.wikidata.org/wiki/Q2625603","display_name":"Population","level":2,"score":0.4325265884399414},{"id":"https://openalex.org/C2776807786","wikidata":"https://www.wikidata.org/wiki/Q5113964","display_name":"Chronic care","level":3,"score":0.4247039258480072},{"id":"https://openalex.org/C112930515","wikidata":"https://www.wikidata.org/wiki/Q4389547","display_name":"Risk analysis (engineering)","level":1,"score":0.32760655879974365},{"id":"https://openalex.org/C74909509","wikidata":"https://www.wikidata.org/wiki/Q10387","display_name":"Gerontology","level":1,"score":0.3238506317138672},{"id":"https://openalex.org/C177713679","wikidata":"https://www.wikidata.org/wiki/Q679690","display_name":"Intensive care medicine","level":1,"score":0.27348437905311584},{"id":"https://openalex.org/C2987552334","wikidata":"https://www.wikidata.org/wiki/Q383126","display_name":"Chronic disease","level":2,"score":0.26021483540534973},{"id":"https://openalex.org/C41008148","wikidata":"https://www.wikidata.org/wiki/Q21198","display_name":"Computer science","level":0,"score":0.17076319456100464},{"id":"https://openalex.org/C99454951","wikidata":"https://www.wikidata.org/wiki/Q932068","display_name":"Environmental health","level":1,"score":0.15315714478492737},{"id":"https://openalex.org/C76155785","wikidata":"https://www.wikidata.org/wiki/Q418","display_name":"Telecommunications","level":1,"score":0.0},{"id":"https://openalex.org/C162324750","wikidata":"https://www.wikidata.org/wiki/Q8134","display_name":"Economics","level":0,"score":0.0},{"id":"https://openalex.org/C50522688","wikidata":"https://www.wikidata.org/wiki/Q189833","display_name":"Economic growth","level":1,"score":0.0}],"mesh":[{"descriptor_ui":"D000203","descriptor_name":"Activities of Daily Living","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D000368","descriptor_name":"Aged","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006760","descriptor_name":"Hospitalization","qualifier_ui":"Q000191","qualifier_name":"economics","is_major_topic":false},{"descriptor_ui":"D006801","descriptor_name":"Humans","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D009730","descriptor_name":"Nursing Assessment","qualifier_ui":"Q000379","qualifier_name":"methods","is_major_topic":true},{"descriptor_ui":"D010043","descriptor_name":"Outcome and Process Assessment, Health Care","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D010360","descriptor_name":"Patient Transfer","qualifier_ui":"Q000191","qualifier_name":"economics","is_major_topic":false},{"descriptor_ui":"D010360","descriptor_name":"Patient Transfer","qualifier_ui":"Q000379","qualifier_name":"methods","is_major_topic":true},{"descriptor_ui":"D012307","descriptor_name":"Risk Factors","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D016294","descriptor_name":"Models, Nursing","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D019090","descriptor_name":"Case Management","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D055318","descriptor_name":"Evidence-Based Nursing","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false}],"locations_count":2,"locations":[{"id":"doi:10.3912/ojin.vol20no03man01","doi":"https://doi.org/10.3912/ojin.vol20no03man01","is_oa":true,"landing_page_url":"https://doi.org/10.3912/ojin.vol20no03man01","pdf_url":"http://www.partnershipforsolutions.org/DMS/files/MedBeneficiaries2-03.pdf","source":{"id":"https://openalex.org/S4210199930","display_name":"OJIN The Online Journal of Issues in Nursing","issn_l":"1091-3734","issn":["1091-3734"],"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["cwts-core","jufo-2","norway-1","poland-40"],"host_organization":null,"host_organization_name":null,"host_organization_lineage":[],"host_organization_lineage_names":[],"type":"journal"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"OJIN: The Online Journal of Issues in Nursing","raw_type":"journal-article"},{"id":"pmid:26882510","doi":null,"is_oa":false,"landing_page_url":"https://pubmed.ncbi.nlm.nih.gov/26882510","pdf_url":null,"source":{"id":"https://openalex.org/S4306525036","display_name":"PubMed","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I1299303238","host_organization_name":"National Institutes of Health","host_organization_lineage":["https://openalex.org/I1299303238"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"Online journal of issues in nursing","raw_type":"Journal Article"}],"best_oa_location":{"id":"doi:10.3912/ojin.vol20no03man01","doi":"https://doi.org/10.3912/ojin.vol20no03man01","is_oa":true,"landing_page_url":"https://doi.org/10.3912/ojin.vol20no03man01","pdf_url":"http://www.partnershipforsolutions.org/DMS/files/MedBeneficiaries2-03.pdf","source":{"id":"https://openalex.org/S4210199930","display_name":"OJIN The Online Journal of Issues in Nursing","issn_l":"1091-3734","issn":["1091-3734"],"is_oa":false,"is_in_doaj":false,"is_core":true,"listed_in":["cwts-core","jufo-2","norway-1","poland-40"],"host_organization":null,"host_organization_name":null,"host_organization_lineage":[],"host_organization_lineage_names":[],"type":"journal"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"OJIN: The Online Journal of Issues in Nursing","raw_type":"journal-article"},"sustainable_development_goals":[{"id":"https://metadata.un.org/sdg/3","score":0.9940000176429749,"display_name":"Good health and well-being"}],"study_designs":[],"awards":[],"funders":[],"has_content":{"grobid_xml":true,"pdf":true},"content_urls":{"pdf":"https://content.openalex.org/works/W2409328652.pdf","grobid_xml":"https://content.openalex.org/works/W2409328652.grobid-xml"},"referenced_works_count":4,"referenced_works":["https://openalex.org/W2439262","https://openalex.org/W2129303710","https://openalex.org/W3035509303","https://openalex.org/W6635523610"],"related_works":["https://openalex.org/W4402860696","https://openalex.org/W4256044501","https://openalex.org/W4366005832","https://openalex.org/W4308512671","https://openalex.org/W4389894627","https://openalex.org/W610324952","https://openalex.org/W2585388927","https://openalex.org/W49702316","https://openalex.org/W2334640301","https://openalex.org/W2883876418"],"abstract_inverted_index":{"Older":[0],"adults":[1,85],"with":[2],"multiple":[3,23],"chronic":[4],"conditions":[5],"complicated":[6],"by":[7],"other":[8],"risk":[9,87],"factors,":[10],"such":[11],"as":[12,91],"deficits":[13],"in":[14,25,59],"activities":[15],"of":[16,33,63,106,131],"daily":[17],"living":[18],"or":[19],"social":[20],"barriers,":[21],"experience":[22],"challenges":[24],"managing":[26],"their":[27],"healthcare":[28,69,95],"needs,":[29],"especially":[30],"during":[31],"episodes":[32],"acute":[34],"illness.":[35],"Identifying":[36],"effective":[37],"strategies":[38],"to":[39],"improve":[40],"care":[41,134],"transitions":[42],"and":[43,97,113,127],"outcomes":[44,90],"for":[45,88,110],"this":[46,64,132],"population":[47,66],"is":[48,71,79],"essential.":[49],"One":[50],"rigorously":[51],"tested":[52],"model":[53],"that":[54],"has":[55],"consistently":[56],"demonstrated":[57],"effectiveness":[58],"addressing":[60],"the":[61,72,107,111,114,123,128],"needs":[62],"complex":[65],"while":[67],"reducing":[68],"costs":[70],"Transitional":[73],"Care":[74],"Model":[75],"(TCM).":[76],"The":[77],"TCM":[78,112],"a":[80,103],"nurse-led":[81],"intervention":[82],"targeting":[83],"older":[84],"at":[86],"poor":[89],"they":[92],"move":[93],"across":[94],"settings":[96],"between":[98],"clinicians.":[99],"This":[100],"article":[101],"provides":[102],"detailed":[104],"summary":[105],"evidence":[108],"base":[109],"model's":[115],"nine":[116],"core":[117,125],"components.":[118],"We":[119],"also":[120],"discuss":[121],"measuring":[122],"TCM's":[124],"components":[126],"overall":[129],"impact":[130],"evidence-based":[133],"management":[135],"approach.":[136]},"counts_by_year":[{"year":2026,"cited_by_count":38},{"year":2025,"cited_by_count":41},{"year":2024,"cited_by_count":32},{"year":2023,"cited_by_count":36},{"year":2022,"cited_by_count":29},{"year":2021,"cited_by_count":46},{"year":2020,"cited_by_count":34},{"year":2019,"cited_by_count":22},{"year":2018,"cited_by_count":22},{"year":2017,"cited_by_count":7},{"year":2016,"cited_by_count":6}],"updated_date":"2026-11-07T11:25:07.637180","created_date":"2016-06-24T00:00:00"}