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Missouri Foundation for Health Joins National Study on Replication of Penn Nursing’s Transitional Care Model

The Missouri Foundation for Health is co-funding the replication and rigorous examination of the outcomes of the Transitional Care Model at the VA St. Louis Health Care System that is part of the national MIRROR-TCM study. Earlier this year, Arnold Ventures awarded a $6 million grant in support of the study at four large health systems, including the Veterans Health Administration.

The VA Health Services Research and Development Service also is a funding partner for this clinical trial, providing support to the VA St. Louis Health Care System and the Louis Stokes Cleveland VA Medical Center sites.

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 chronically ill older adults. “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 health and social needs. Evidence that the TCM is generalizable also will encourage voluntary adoption among other health systems,” 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 overall goal of the MIRROR-TCM 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. Nine hospitals located in five states which are part of Swedish Health Services, Trinity Health-Michigan, University of California San Francisco (UCSF) Health, and the Veterans Health Administration (VHA), are recruiting 1,600 Medicare patients to participate in this RCT. Naylor’s team at Penn Nursing serves as the coordinating center providing technical assistance and training to participating health systems. An independent evaluation led by Randall Brown, PhD, and Arka Ghosh, PhD, will be conducted at Mathematica.

The Missouri Foundation for Health’s support of the VA St. Louis Health Care System is a promising step forward for sustainability of the TCM. The Veterans Research and Education Foundation of St. Louis (VREFSTL) partners with the VA St. Louis Health Care System, with a focus on the health and well-being of Veterans through research and education conducted at within the VA St. Louis Health Care System. “The MIRROR-TCM study is aligned with our vision to ensure that every Veteran receives the best possible care through research-related health care improvements,” says Mary Coleman, Executive Director of VREFSTL.

The Penn team also will examine factors that may influence implementation of the TCM across health systems. “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.