Karen B. Hirschman, PhD, MSW

Research Professor

Karen Hirschman has always been interested in helping people during times of health-related transitions in care.

After completing a post-doc at Penn’s Perelman School of Medicine in age-related neurodegenerative disease research, she joined Penn Nursing’s faculty. Dr. Hirschman’s research focuses on transitions in care for older adults with multiple chronic conditions, medical decision-making, palliative care, and family caregiver burden with older adults, with an emphasis on individuals living with dementia and their family members.

My days as a geriatric social worker shaped my interest in improving care for older adults as they move across settings and levels of care.


  • PhD, University of Pennsylvania, 2001
  • MSW, University of Pennsylvania, 1996
  • BS, University of Pittsburgh, 1993


Dr. Hirschman is a member of the Transitional Care Model team, led by Dr. Mary Naylor. This rigorously-tested advanced practice nurse-led model targets high-risk hospitalized older adults with multiple chronic conditions and focuses on improving outcomes and reducing acute care resource use (e.g., hospitalizations, emergency department visits). Advanced practice registered nurses (APRNs) transition older adults from the hospital to other health care settings and home, engaging patients and their family caregivers and collaborating with clinicians throughout the transition. Multiple NIH-funded randomized controlled trials and comparative effectiveness studies have found the model effective in improving outcomes for hospitalized older adults and their family caregivers.

The team now studies how service providers adapt the model to their environments and what components are most important to patients and families.  

Transitional Care Features and Scaling

Dr. Hirschman is a co-investigator in Penn Nursing’s participation in Project ACHIEVE, a multi-site effort funded by the Patient-Centered Outcomes Research Institute to identify the most effective features of transitional care, and to learn from patients and caregivers which outcomes matter most to them. The study involves focus groups, interviews, and a national survey of patients, caregivers, and providers. (ACHIEVE stands for Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence).

In another study funded by the Robert Wood Johnson Foundation, Dr. Hirschman is working with other members of the Transitional Care Model team and scientists at Stevens Institute of Technology to develop a “policy flight simulator” (pioneered by Stevens) to scale the model.  The simulator will allow users to create scenarios for scaling the model within parameters they set: target population or geographical area, type of staffing, reimbursement mechanisms, etc.  The goal is to answer questions such as, “If we scale the model this way, what would it cost and what would it save?”

Opportunities to Learn and Collaborate at Penn Nursing

Through Penn Nursing’s NewCourtland Center for Transitions in Health, Dr. Hirschman works with nursing faculty and students interested in research about how the nursing profession can ease major health transitions facing chronically ill adults and their families. Faculty and doctoral students regularly present their work and collaborate on writing grant proposals and journal articles.

Dr. Hirschman collaborates with health economists, biostatisticians, and others in her work both independently and on the refinement of the Transitional Care Model. She also mentors students at all levels of their education in her areas of research expertise.

Selected Career Highlights

  • Fellow, Gerontological Society of America
  • Editorial Board, International Journal of Chronic Disease
  • Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania

Accepting Mentees?

  • Yes

Accepting Fellows?

  • Yes

Selected Publications

  • Hirschman KB, Toles MP, Hanlon AL, Huang L, Naylor MD. What Predicts Health Care Transitions for Older Adults Following Introduction of LTSS? J Appl Gerontol. 2020;39(7):702-711. https://doi.org/10.1177/0733464819833565 PMID: 30819004 PMCID: PMC6713625

  • Riegel B, Hanlon A, Coe NB, Hirschman KB, Thomas G, Stawnychy M, Wald JW, Bowles KH. Health Coaching to Improve Self-Care of Informal Caregivers of Adults with Chronic Heart Failure – iCare4Me: Study Protocol for a Randomized Controlled Trial. Contemporary Clinical Trials. 2019; 85:105845. PMID: 31499227. PMCID: PMC6815729. DOI: 10.1016/j.cct.2019.105845

  • Pauly MV, Hirschman KB, Hanlon AL, Bowles KH, Bradway C, McCauley KM, Naylor MD. Cost impact of the transitional care model for hospitalized cognitively impaired older adults. Journal of comparative effectiveness research. 2018. (epub ahead of print)

  • Pauly MV, Hirschman KB, Hanlon AL, Bowles KH, Bradway C, McCauley KM, Naylor MD. Cost impact of the transitional care model for hospitalized cognitively impaired older adults. Journal of comparative effectiveness research. 2018;7(9):913-922 https://doi.org/10.2217/cer-2018-0040

  • Naylor MD, Hirschman KB, Hanlon AL, Bowles KH, Bradway C, McCauley KM, Pauly MV. Effects of Alternative Interventions among Hospitalized, Cognitively Impaired Older Adults. Journal of Comparative Effectiveness Research. 2016; 5(3), 259-272.

  • Zubritsky, C., Abbott, K., Hirschman, K.B., Hanlon, A., Bowles, K.H., & Naylor, M.D. (2016). Changes over time in emotional status among older adults new to receiving long-term services and supports. Journal of Best Practices in Mental Health, 12(2), 63-80.

  • Van Cleave J, Egleston B, Abbott KM, Hirschman KB, Rao A, Naylor MD. Multiple chronic conditions and hospitalizations among recipients of long-term services and supports. Nursing Research. 2016; 65(6), 425-434.

  • Hirschman, K.B., Shaid, E., McCauley, K., Pauly, M.V., & Naylor, M.D. (2015). Continuity of care: The Transitional Care Model. The Online Journal of Issues in Nursing, 20, published online 9/30/2015.
  • Hirschman, K.B., Shaid, E., Bixby, M.B., Barg, R., Badolato, D.M., Byrnes, R., et al. (2015). Transitional care in the Patient Centered Medical Home: Lessons in adaptation. Journal of Healthcare Quality, published online 4/9/2015, (PMID: 26042750).
  • Towsley, G., Hirschman, K.B., & Madden, C. (2015). Conversations about end of life: Perspectives of nursing home residents, family, and staff. Journal of Palliative Medicine, 18, 421-428. (PMID: 25658608).10.1089/jpm.2014.0316

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