Abstract
To reduce avoidable hospital readmissions and improve transitions between healthcare settings, Virtua Home Care implemented a Transitions of Care Program based on the Transitional Care Model developed at the University of Pennsylvania School of Nursing. Home care nurses were educated to be transitional care nurses and provided intensive education and follow-up for patients with chronic diseases who were identified as having a high risk of readmission. This program, which provides services to patients enrolled in fee-for-service (FFS) Medicare and who are eligible to receive the home health benefit, has successfully reduced hospital readmissions. This article describes Virtua Home Care's journey in adapting and implementing an evidence-based care transitions model.