RESUMO
With the increasing prevalence of chronic obstructive pulmonary disease (COPD) and the extremely high mortality, disability, symptom burden and dysfunction, as well as the need for continuous drug management and care and increased rehospitalization rate, it brings patients, families and even society huge economic burden. The transitional care model provides non-drug treatment method to help patients get through the transition period safely and steadily, it also improves patients' self-care ability, quality of life and reduce hospital readmission. This review will start from the concept of disease management in transitional period, elaborate on the problems and core elements of transitional caring, then discuss the application of advanced practice nurse-dominated transitional caring mode in COPD, so as to provide theoretical and practical basis for improving the quality of chronic diseases management in China.