Abstract: In order to establish an effective transitional care mode, the transitional care center was established in September 2012. Accordingly, a series of working systems and management practice were developed, full-time and part-time nursing positions were established, and electronic patient file management, telephone follow-up and warm SMS tips, home of specialist services,health lectures, and other methods were carried out to run extended care. Within one year, more than 1200 electronic patient files were built, over 3000 telephone cares follow-up for discharged patients and 32 times health lectures were carried out, and more than 120 cases received home visit services. The work of transitional care center ensured the continuity of patient rehabilitation , and improved patients' satisfaction and self-management skills.