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Trinity Health - IHA Transitional Care Model Registered Nurse in Ann Arbor, Michigan


The Transitional Care Model Registered Nurse (TCM RN) provides direct care and coordinates care for older adults with complex health and social needs across episodes of acute illness. Using a research-based protocol as the guide, the TCM RN conducts a comprehensive patient and family caregiver assessment to determine priority needs and, in collaboration with the patient’s physician and other health care and community-based team members, designs and implements an individualized plan of care extending from hospital admission to an average of two months post-hospital discharge. Ongoing evaluation of processes and outcomes of care are key features of the model.


  • Performs comprehensive and accurate physical, mental, emotional and social assessments in hospital and community settings.

  • Coordinates care in collaboration with primary care doctors, specialists and other health and community-based team members to achieve goals (symptoms, stability and progress) and patient responses.

  • Synthesizes data from the health history, physical examination and diagnostic data to consolidate a patient problem list that includes medical diagnoses, nursing needs/problems and health risks.

  • Creates individualized, prioritized plan of care addressing urgent, intermediate and long-term goals negotiated with the patient and family caregiver, including, written:

  • Emergency plan

  • Symptom management plan

  • Medication schedule

  • Improved adherence plan

  • Dietary plan

  • Exercise/activity plan

  • Plan to enhance quality of life

  • Advance directives

  • Plan to address behavioral health needs

  • Plan to access essential community-based services

  • Supports patients in meeting their goals via effective management of priority health and social needs, implementation of evidence-based guidelines, advanced care planning and other strategies designed to improve health and quality of life outcomes.

  • Collaborates with providers and multidisciplinary team members to ensure that current plan of care reflects patient status and responses.

  • Identifies risk factors and develops a plan that stresses early problem recognition, management of co-morbidities, strategies to prevent exacerbations or improve the patient’s health and quality of life.

  • Provides direct care and coordinates care for older adults with complex health and social needs across episodes of acute illness in hospital, skilled nursing facilities (if referred) and patients’ homes.

  • Accompanies patient (and family caregiver, if possible) to selected office visits with primary care and specialist providers to support patient.

  • Orders/adjusts medication and diagnostic tests appropriate to protocol or collaborative plan negotiated with the patient’s primary and specialist providers.

  • Communicates needs, process and evaluation to health and community-based team through established verbal and written processes.

  • Collaborates with health and social service providers in a variety of settings to assure continuity of care and implementation of appropriate care needs to support the plan of care.

  • Prepares and presents clinical cases for case conference for discussion and consultation.


  • Creates a positive, professional, service-oriented work environment for staff, patients and family members by supporting the IHA CARES mission and core values statement.

  • Must be able to work effectively as a member of the clinical team.

  • Successfully completes IHA’s “The Customer” training and adheres to IHA’s standard of promptly providing a high level of service and respect to internal or external customers.

  • Maintains knowledge of and complies with IHA standards, policies and procedures, including IHA’s Employee Handbook.

  • Maintains complete knowledge of office services and in the use of all relevant office equipment, computer, and manual systems.

  • Maintains strict patient and employee confidentiality in compliance with IHA and HIPAA guidelines

  • Serves as a role model, by d emonstrating exceptional ability and willingness to take on new and additional responsibilities. Embraces new ideas and respect cultural differences.

  • Uses resources efficiently.

  • Responsible for ongoing professional development – maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.


    Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position. Care Management Metrics including productivity and Advanced Care Practice (ACP) education and completion, and others defined by program.




    Minimum of a Master of Science in Nursing. Successful completion of a web-based seminar and orientation program on transitional care.

    CREDENTIALS / LICENSURE : Valid, unrestricted RN license in the State of Michigan; Valid CPR certification.

    MINIMUM EXPERIENCE : Familiarity with home care or discharge planning care processes and standards of care.


  • Master’s degree in Nursing

  • State of Michigan Nurse Practitioner license

  • Certified through the National Board depending on specialty

  • State of Michigan license as an RN and specialty certification as a Nurse Practitioner


  • Ability to balance and maintain a full patient case load while completing clinical assessments and documentation accurately and in a timely manner.

  • Exercises sophisticated clinical judgment and implements evidence-based guidelines applicable to each patient’s situation.

  • Knowledge of patient care procedures and organizational policies related to position responsibilities.

  • Knowledge of chronic conditions, evidence-based guidelines, prevention, wellness, health risk assessment, and patient education

  • Excellent assessment and triage skills (per specialty population expectations). Understands chronic disease management strategies and is able to implement appropriate protocols and guidelines.

  • Familiarity with home care or discharge planning care processes and standards of care.

  • Ability to access and engage community-based services.

  • Proficient in medical terminology.

  • Proficient in operating a standard desktop and Windows-based computer system, including but not limited to, electronic medical records and other care management and/or clinical IS systems, email, e-learning, intranet, Microsoft Word and Excel, and computer navigation needed to complete the tasks of clinical care and performance reporting. Ability to use other software as required while performing the essential functions of the job.

  • Excellent communication skills in both written and verbal forms, including proper phone etiquette. Ability to speak before groups of people.

  • Ability to work autonomously and collaboratively in a team-oriented environment; displays courteous and friendly demeanor.

  • Ability to work effectively with various levels of organizational members and diverse populations including IHA staff, providers, provider leadership, patients, family members, insurance carriers, vendors, external customers and community groups.

  • Good organizational and time management skills to effectively juggle multiple priorities and time constraints.

  • Ability to exercise sound judgement and participate in active problem-solving. Demonstrated skills with influencing and negotiating individual and group decision-making.

  • Ability to handle patient and organizational information in a confidential manner.

  • Knowledge of the compliance and quality aspects of clinical care and patient privacy and best practices in medical office operations.

  • Ability to travel to other office/practice sites and meeting, training, patient appointment and home visit locations.

  • Successful completion of IHA competency-based program within introductory and training period.

  • Successfully complete an intensive orientation and training program to deliver TCM interventions.


  • Physical activity that often requires keyboarding, phone work and charting.

  • Physical activity that often requires extensive time working on a computer.

  • Physical activity that often requires handling and lifting patients walking, standing, bending, stooping, reaching, climbing, kneeling and/or twisting.

  • Physical activity that often requires other lifting, pushing and/or pulling up to 20 pounds.

  • Specific vision abilities required include close vision, depth perception, peripheral vision and the ability to adjust and focus.

  • Manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.

  • Must hear and speak well enough to conduct business over the telephone or face to face for long periods of time in English.


    This job operates in a medical facility and requires regular walking to various locations around the hospital/clinic. Employees will be working where there is patient care equipment. Hazardous materials, including blood borne pathogens and bodily fluids are also present. Exposure to sharps, x-rays, patients' conditions and some unpleasant sights, smells and contagious diseases is possible. This position requires significant interaction with people (many of whom are scared, hurt and/or ill) which can be stressful and result in competing priorities. The job requires daily travel to hospitals, patient homes and physician offices.