Abstract: To discuss the national health demand with the development of transitional care under the background of the Health China, and the opportunities and challenges of transitional care. The authors introduced the development of their hospital’s transitional care system since 2007, including the transitional care service mode, framework, and effects. They discussed multiple transitional care service programs, including discharge planning, referral services, long-term care, home care, chronic diseases case management, follow-up counseling, and external liaison, based on nearly 10 years of exploration and practice. Their experience provided a new thinking for the development of transitional care in China, and was helpful to promote long-term care insurance system and nurses’ multi-spot practice.