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The Transitional Care Model (TCM)

1. An evidence-based assessment tool with 10 screening criteria that are found to predict *higher risk* for readmission once the patient transitions from hospital to home.
2. High-risk criteria include: Being age 80 or older; moderate to severe functional deficits; depressive symptoms; four or more active co-existing health conditions; six or more prescribed medications; an inadequate support system; low health literacy; documented history of nonadherence to therapeutic regimen; cognitive impairment.
3. Patients are also considered high risk for poor transitions if they have had two or more hospitalizations in the past 6 months or a hospitalization in the past 30 days.


Older adults make up _ of non-obstetric hospital days.



_ of older adults have chronic conditions.



According to an IOM report, *adverse events* are common for older adults, particularly in the areas of _

1. Pressure ulcers.
2. Medication errors.
3. Delirium.
4. Physical restraint use.


"NICHE" stands for _

Nurses Improving Care to Health systems Elders.


ACE Unit

"Acute Care of the Elderly" Unit - all staff are GRNs (Geriatric Resource Nurses).


The Geriatric Resource Nurse (GRN) model offers a unit-based approach to managing the needs of older adults by _

Adding the resources of a staff nurse who has participated in didactic and often also clinical training programs in the hospital.