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中文摘要：
本文通过介绍美国老年人过渡期护理服务的相关概念、团队成员与职责、评价指标及效果分析等内容,为我国老年人过渡期护理服务的发展提供了思路和建议,以保证老年人在医院、社区及家庭的过渡期获得连续无缝隙的护理服务。
英文摘要：
This paper introduced the relevant concepts,team members and their responsibilities,evaluation indexes and effect analysis of elderly transitional care in the USA,which can provide good thoughts and instructions for the development of the elderly transitional care in China,so as to ensure the elderly get continuous seamless nursing services during the transition from hospitals to communities or families.
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