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Penn Nursing Professor Receives Lienhard Award from National Academy of Medicine for Pioneering the Field of Transitional Care

The National Academy of Medicine today announced Mary D. Naylor, PhD, RN, FAAN, the Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health, is the recipient of the 2022 Gustav O. Lienhard Award for Advancement of Health Care for improving the lives of millions of older adults living with complex health and social needs through her role as the architect of the Transitional Care Model and pioneer of the field of transitional care. The award will be presented at the National Academy of Medicine’s annual meeting on Oct. 16. Naylor is one of four University of Pennsylvania faculty, and the third from the School of Nursing, to have received this national honor.

“Penn Nursing has a legacy of innovation, discovery, and advocacy to provide health care for the most vulnerable in our health care system,” said Penn Nursing Dean Antonia M. Villarruel. “Dr. Naylor’s work has been a leader in building that legacy. We are incredibly proud of her accomplishments and the impact she has had and continues to have on health care—this is a well-deserved honor that reflects the excellence of her scholarship and the innovation-centered environment we embrace at Penn Nursing to build the future of nursing. We congratulate Dr. Naylor on this prestigious honor.”

For more than 20 years, Naylor has led a multidisciplinary team in generating and disseminating research findings to enhance care and outcomes for chronically ill older adults and their caregivers. The hallmarks of the Transitional Care Model (TCM) that Naylor developed include: engaging at-risk older adults and caregivers during episodes of acute illness; establishing trusting relationships between advanced practice registered nurses (APRNs) and older adults and their caregivers; identifying and then advocating for older adults’ goals to drive their plans of care; providing continuity of care by the same APRN throughout a patients’ illness experiences; and coordinating care with multiple clinicians and staff across settings.

Findings from three consecutive National Institutes of Health funded randomized controlled trials led by Naylor consistently demonstrated the effectiveness of the TCM in enhancing the care experiences of at-risk hospitalized older adults as they transitioned to home, while improving their functional status and quality of life. These outcomes were achieved by different racial groups and accompanied by significant reductions in avoidable re-hospitalizations and substantial health care savings. Currently, Arnold Ventures’ Moving the Needle Initiative is supporting a multisite replication of the TCM in healthcare systems across the U.S. According to the Center for Health Care Strategies, the TCM has been implemented in hundreds of health care organizations and communities in 46 states across the U.S.

To advance the field of transitional care, Naylor has engaged with policymakers, including testifying before U.S. congressional committees, to inform health care policies that support the transitional care needs of at-risk older adults and their family caregivers. She served six years both as a commissioner on the Medicare Payment Advisory Commission and as a board member of the National Quality Forum, where she successfully advocated for better measures of, and increased payment for transitional care services. Prior to the passage of the Affordable Care Act (ACA), she partnered with the AARP policy leadership team to advocate for the inclusion of evidence-based transitional care in multiple care delivery and payment provisions of the ACA, which they ultimately achieved.

As director of Penn Nursing’s NewCourtland Center for Transitions and Health, Naylor leads faculty members and pre-doctoral and postdoctoral fellows on initiatives designed to translate findings generated from a range of evidence-based solutions that will enhance older adults’ health and well-being and advance health equity. For more than a decade, she has led a National Institute of Nursing Research-funded training grant to prepare the next generation of nurse scholars to generate and translate new knowledge focused on improving the care experience, health and quality of life of at-risk older adults and their caregivers. Naylor also has mentored and collaborated with hundreds of clinicians and clinical scholars representing a range of disciplines throughout the U.S. and abroad who are committed to implementing high-quality transitional services.

Moreover, Naylor has a long history of championing the profession of nursing. From 2005-2015, Naylor served as the national program director for the Robert Wood Johnson Foundation-sponsored Interdisciplinary Nursing Quality Research Initiative, which awarded 40 teams throughout the U.S. with highly competitive grants to support interdisciplinary teams of researchers who conducted rigorous studies linking nursing to patient care quality and outcomes.

“Overcoming barriers to initial implementation of the Transitional Care Model, and more recently the added challenges due to the COVID-19 pandemic, Dr. Naylor’s persistence over the past two decades has enabled older adults to receive the quality and continuity of care they deserve,” said National Academy of Medicine President Victor J. Dzau. “Her pioneering research placed a national spotlight on what is possible when health and social care systems are aligned with people’s goals and changing needs, in order to address social determinants at the point of care. Dr. Naylor’s tireless efforts to establish the field of transitional care for older adults and their caregivers, coupled with her championing of nurses and preparing the next generation for care transitions, make her most deserving of this prestigious award.”

In addition to being elected to the NAM in 2005, Naylor is a member of the NAM’s Leadership Consortium: Collaboration for a Learning Health System and co-chairs its Culture, Inclusion, and Equity Action Collaborative, designed to advance health equity across the U.S. health system. Naylor is the 2016 recipient of the AcademyHealth Distinguished Investigator Award, a recognition for her significant and lasting contributions to the field of health services research.

Naylor is the 37th recipient of the Lienhard Award. Given annually, the award recognizes outstanding national achievement in improving personal health care in the United States. Nominees are eligible for consideration without regard to education or profession, and award recipients are selected by a committee of experts convened by the National Academy of Medicine. This year’s selection committee was chaired by Clyde W. Yancy, vice dean for diversity and inclusion; Magerstadt Professor of Medicine; professor of medical social sciences and internal medicine; and chief of the Division of Cardiology, Northwestern University Feinberg School of Medicine

The Lienhard Award is funded by an endowment from the Robert Wood Johnson Foundation. Gustav O. Lienhard was chair of the foundation’s board of trustees from the organization’s establishment in 1971 to his retirement in 1986 — a period in which the foundation moved to the forefront of American philanthropy in health care. Lienhard, who died in 1987, built his career with Johnson & Johnson, beginning as an accountant and retiring 39 years later as its president.

The National Academy of Medicine, established in 1970 as the Institute of Medicine, is an independent organization of eminent professionals from diverse fields including health and medicine; the natural, social, and behavioral sciences; and beyond. It serves alongside the National Academy of Sciences and the National Academy of Engineering as an adviser to the nation and the international community. Through its domestic and global initiatives, the NAM works to address critical issues in health, medicine, and related policy and inspire positive action across sectors. The NAM collaborates closely with its peer academies and other divisions within the National Academies of Sciences, Engineering, and Medicine.