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Arnold Ventures Awards $6 Million Grant to Study Replication of Penn Nursing’s Transitional Care Model

The study will evaluate the effectiveness of TCM in reducing rehospitalizations and promote widespread use of the program in a number of health systems.

A $6 million grant from Arnold Ventures will support replication and rigorous study of the outcomes of the Transitional Care Model (TCM) in four U.S. health care systems. Designed by a team at the University of Pennsylvania School of Nursing (Penn Nursing), the TCM has been proven in multiple National Institutes of Health (NIH)-funded randomized clinical trials (RCTs) to improve health outcomes, reduce rehospitalizations and decrease total health care costs among the growing population of Medicare beneficiaries.

“To achieve positive outcomes for older adults with complex health and social needs, an advanced practice registered nurse (APRN) collaborates with patients, their family caregivers, and healthcare teams to design and implement individualized plans of care that extend from hospital to home,” explained the project’s lead, Mary Naylor, PhD, RN, FAAN, the Marian S. Ware Professor in Gerontology and the Director of the NewCourtland Center for Transitions and Health. Naylor is the architect of the TCM at Penn Nursing.

The study will evaluate the effects of the TCM in nine hospitals located in five states which are part of Swedish Health Services, Trinity Health, University of California San Francisco (UCSF) Health, and the Veterans Health Administration. Together, these systems will recruit 1,600 Medicare patients to participate in this RCT. Mathematica will conduct an independent evaluation, led by Randall Brown, PhD and Arka Ghosh, PhD.

“TCM has very promising evidence of sizable reductions in rehospitalizations and net healthcare costs among Medicare beneficiaries,” says Erin Crossett, Evidence-Based Policy Manager of Arnold Ventures that awarded the grant. The grant is part of the organization’s Moving the Needle initiative to expand delivery of programs that have been rigorously shown to improve important life outcomes, ensuring significant headway against U.S. social problems. “The successful replication of TCM would provide convincing evidence that TCM could be used in hospitals nationwide to improve patient health and generate major healthcare savings” said Crossett.

When the trial is launched, the Penn Nursing team (led by Naylor) will coordinate the initiative, providing participating sites with the training and support essential to implement the TCM as designed. The overall goal of the study is to determine if the health and economic benefits demonstrated by the TCM in NIH-funded RCTs conducted in Pennsylvania can be replicated both within and across health systems spread throughout the U.S.

“If the TCM’s effects can be reproduced, participating health systems are committed to spread the model, accelerating their ongoing efforts to improve the care and outcomes of the growing population of older adults living with complex needs. Evidence that the TCM is generalizable also will encourage voluntary adoption among other health systems,” says Naylor.

The Penn team also will examine factors that may influence the implementation and, if successful, health systems’ expansion of the TCM. “With a diverse set of hospitals in terms of size, geographic location, patient population, and post-acute and community-based service partners, the RCT findings will provide an actionable path for the Centers for Medicare and Medicaid Services and other payers to reduce healthcare costs among Medicare beneficiaries, while maintaining high quality care,” says Naylor.