Mary D Naylor, PhD, FAAN, RN
Marian S. Ware Professor in Gerontology; Director of NewCourtland Center for Transitions and Health

Contact Information
University of Pennsylvania School of Nursing
Room 341 Fagin Hall
418 Curie Blvd.
Philadelphia, Pennsylvania 19104-4217
tel: (215) 898-6088

Mary D. Naylor, Ph.D., RN, FAAN, is the Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. Dr. Naylor is the architect of the Transitional Care Model (TCM), designed to positively impact the care and outcomes of chronically ill older adults who are navigating fragmented systems of care. In collaboration with a multidisciplinary team of clinical scholars and health services researchers, she has tested the TCM and translated the evidence generated within health systems and communities throughout the US and across the globe. Initially, her team’s efforts were focused on the transitions of older adults from hospitals to home. More recently, they have extended their work to prevent avoidable hospitalizations among older adults living in their communities. This evidence-based solution has not only demonstrated better care while reducing health care costs but, importantly also has improved older adults’ functional status and quality of life.

Students at all levels—from undergraduates to post-doctoral fellows—have the opportunity to be mentored by Dr. Naylor and members of the NewCourtland Center for Transitions and Health, the research center which she directs. Additionally, she leads a seminar as part of the course of study for first year undergraduate students: The Nature of Nursing Practice (N101) and Situating the Practice of Nursing (N102). Dr. Naylor credits the perspectives of students with energizing the work and contributions of the NewCourtland Center in enhancing the care and outcomes of chronically ill adults and their family caregivers.

Findings from three multi-site, National Institute of Nursing Research (NINR) funded randomized clinical trials (RCTs) led by Dr. Naylor consistently demonstrated the effectiveness of this advanced practice nurse led, team-based innovation targeting high risk, cognitively intact older adults transitioning from hospital to home, in improving their health care experiences, enhancing their health and quality of life outcomes, and reducing overall health care costs. Subsequently, her team expanded the focus of the care model to hospitalized older adults whose care is complicated by cognitive impairment. Unlike earlier RCTs, this National Institute on Aging (NIA) funded clinical trial compared the effectiveness of the TCM to other evidence-based approaches and resulted in improved patient and health resource outcomes compared to other proven strategies. Another NIA-NINR funded study examined the potential value of the TCM in meeting the needs of frail older adults receiving long-term services and supports. With the support of multiple foundations, Dr. Naylor and her team also have tested the integration of the TCM within primary care settings. In collaboration with leaders at multiple patient-centered medical homes (PCMHs), a nurse-physician team approach to addressing the needs and goals of high risk community-based older adults was designed and found to improve outcomes relative to the PCMH only.

• Currently Funded Grants

• NewCourtland Center for Transitions and Health

Clinical Practice
To accelerate the movement of evidence from her team’s work into practice and with the support of many foundations, Dr. Naylor has partnered with leaders of health systems, payers and other stakeholders. A 2015 study funded by the Robert Wood Johnson Foundation (RWJF) revealed that approximately 60% of responding health systems have adopted or adapted the TCM into practice. Another RWJF study is supporting a partnership with system engineers at the Stevens Institute of Technology to develop a simulation model that will accelerate decision making regarding adoption of the TCM. The Coalition for Evidence-Based Policy (now a part of the Laura and John Arnold Foundation) has recognized the TCM as a “top-tiered” evidence-based approach that, if scaled, could have a positive impact on the health and well-being of chronically ill older adults, while assuring wiser use of societal resources.


For the past eight years, Dr. Naylor served as the National Program Director of the Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI), designed to generate, disseminate and translate research to understand how nurses contribute to the quality of patient care. Dr. Naylor was elected to the National Academy of Medicine (NAM) in 2005; she is a member of NAMs Leadership Consortium for Value & Science-Driven Health Care and co-chairs the Care Culture and Decision-Making Innovation Collaborative. Dr. Naylor also is a member of the ABIM Foundation Board of Trustees, RAND Health Board of Advisors and the Agency for Healthcare Research and Quality (AHRQs) National Advisory Council. In 2016, she completed her six year term as a member of Medicare’s Payment Advisory (MedPAC) Commission.
• Honors/Awards Details »

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Nurses will play a pivotal role in addressing the health care needs of people throughout the 21st century. The cutting edge science, led by nurses and designed to advance knowledge related to promoting healthy lifestyles and caring for the chronically ill, will position nurses and other health team members to make a major difference in the lives of these people.