Sign In
Penn Nursing > Media > Transitional Care Model

Transitional Care Model is basis for Medicare benefit impacting hospital discharge planning

Enhancing Quality of Life and Saving Taxpayer Dollars

Nurse-conducted research is poised to make an impact on the nation's healthcare and budget by becoming a Medicare benefit.

A multidisciplinary team, led by Mary D. Naylor, PhD, FAAN, RN, 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, has been at the forefront of research producing the evidence for a new way to assist and manage the health problems of the nation's elderly, particularly those with multiple health problems, as they move from hospital to home. This evidence-based model of transitional care has the potential of enhancing the quality of life for patients and their families, while also saving taxpayers millions of dollars annually.

Transitional Care Model and Advanced Practice Nurses

This important legislation is designed to eliminate thousands of preventable hospital readmissions that occur each year by providing high quality transitional care to high-risk Medicare beneficiaries throughout episodes of acute illness. The model involves care by advanced practice nurses, throughout elder's acute episodes of illness.

Since 1989, Dr. Naylor has led an interdisciplinary program of research designed to improve outcomes and reduce costs of care for vulnerable community-based elders. To date, Dr. Naylor and her research team have completed three National Institute of Nursing Research (NINR)-funded randomized clinical trials focusing on discharge planning and home follow- up of high-risk elders by advanced practice nurses. Dr. Naylor and her team of researchers partnered with Aetna Corporation and Kaiser Permanente Health Plan to apply the model in everyday practice. Throughout testing, the model has proven to provide improved quality of care at lower cost by reducing the number of hospital readmissions.

Transitional Care Model (PDF) »