Mary D. Naylor, PhD, RN, FAAN

Marian S. Ware Professor in Gerontology

Director of the NewCourtland Center for Transitions and Health

Mary Naylor is a pioneer in the design, evaluation, and spread of health care innovations that have significantly improved the outcomes of chronically ill older adults and their family caregivers, while reducing health care costs. In collaboration with a multidisciplinary team of clinical scholars and health services researchers, her work has resulted in the Transitional Care Model, a cost-effective advanced practice nurse-led model to improve the transitions of older adults who are navigating complex and often fragmented systems of care.

Initially, her team’s efforts were focused on the transitions of older adults from hospitals to home. More recently, they have extended their work to prevent avoidable hospitalizations among older adults living in their communities. This evidence-based solution has not only demonstrated better care but also has improved older adults’ functional status and quality of life. Dr. Naylor has demonstrated how knowledge generated from her research can be used to address the broader challenges associated with chronic illness, the endemic problem of this century.

We collaborate with the best minds to design and implement solutions that advance health, while encouraging the next generation of nurses to do even better


  • PhD, University of Pennsylvania, 1982
  • MSN, University of Pennsylvania, 1973
  • BSN, Villanova University, 1971


Students at all levels—from undergraduates to post-doctoral fellows—have the opportunity to be mentored by Dr. Naylor and members of the NewCourtland Center for Transitions and Health, the research center which she directs. Additionally, she leads a seminar as part of the course of study for first-year undergraduate students.


Dr. Naylor has worked tirelessly to advocate for evidence-based changes in health care practices and policies across the globe. As a member of the Medicare Payment Advisory Commission, for example, Dr. Naylor advised the U.S. Congress on policies designed to offer a more promising future for Medicare beneficiaries. As a result, the use of evidence-based transitional care is now included in multiple policies designed to foster health care delivery and payment reforms, including several provisions of the 2010 Affordable Care Act.

Clinical Practice

Findings from three multi-site, National Institute of Nursing Research-funded randomized clinical trials led by Dr. Naylor have consistently demonstrated the effectiveness of the Transitional Care Model in improving high-risk older adults’ health care experiences, and health and quality of life outcomes, while reducing overall health care costs.

In another clinical trial, funded by the National Institute on Aging, the model was refined for hospitalized older adults whose care is complicated by cognitive impairment and shown to improve patient and health resource outcomes when compared to other proven strategies. Another National Institute on Aging/National Institute of Nursing Research-funded study examined the potential value of the model for frail older adults receiving long-term services and supports.

With the support of multiple foundations, Dr. Naylor and her team also have tested the integration of the Transitional Care Model within primary care settings. In collaboration with leaders at multiple patient-centered medical homes, they designed a nurse-physician team approach to addressing the needs and goals of high-risk community-based older adults and found that it improved outcomes relative to the patient-centered medical homes only.

To accelerate the movement of this evidence into practice and with the support of many foundations, Dr. Naylor has partnered with leaders of health systems, payers, and other stakeholders. A 2015 study funded by the Robert Wood Johnson Foundation revealed that 59% of 582 responding health systems have adopted or adapted the Transitional Care Model. Another Robert Wood Johnson Foundation study is supporting a partnership with system engineers at the Stevens Institute of Technology to develop a simulation model that will accelerate decision-making regarding adoption of the model. The Coalition for Evidence-Based Policy (now a part of the Laura and John Arnold Foundation) has recognized the model as a “top-tiered” evidence-based approach that, if scaled, could have a positive impact on the health and well-being of chronically ill older adults, while assuring wiser use of societal resources.

Selected Career Highlights

  • Distinguished Investigator Award, AcademyHealth
  • Fellow, National Academy of Medicine, member, Leadership Consortium for Value & Science-Driven Health Care, and Co-Chair, Care Culture and Decision-Making Innovation Collaborative
  • Member, RAND Health Board of Advisors
  • Member, Agency for Healthcare Research and Quality’s National Advisory Council
  • 2015-2016 Presidential Chair, University of California, San Francisco

Accepting Mentees?

  • Yes

Accepting Fellows?

  • Yes

Selected Publications

  • Naylor, M.D., Shaid, E.C., Carpenter, D., Gass, B., Levine, C., Li, J., … Williams, M.V.  (2017). Components of comprehensive and effective transitional care.  Journal of the American Geriatrics Society, published online 4/3/2017, (PMID: 28369722). doi:10.1111/jgs.14782.

  • Hirschman, K.B., Shaid, E., Bixby, M.B., Badolato, D.J., Barg, R., Byrnes, M.B., …Naylor, M.D. (2017). Transitional care in the patient-centered medical home: Lessons in adaptation. Journal for Healthcare Quality, 39(2), 67-77.  doi:10.1097/01.JHQ.0000462685.78253.e8.

  • Naylor, M.D., Hirschman, K.B., Hanlon, A.L., Bowles, K.H., Bradway, C., McCauley, K.M., & Pauly, M.V. (2016). Effects of alternative interventions among hospitalized, cognitively impaired older adults. Journal of Comparative Effectiveness Research, 5(3), 259-272. (PMID: 27146416). doi:10.2217/cer-2015-0009

  • Van Cleave, J.H., Egleston, B.L., Abbott, K.M., Hirschman, K.B., Rao, A., & Naylor, M.D. (2016). Multiple chronic conditions and hospitalizations among recipients of long-term services and supports. Nursing Research, 65(6):425-434. (PMID: 27801713).

  • Naylor. M., & Berlinger. N. (2016). Transitional Care: A Priority for Health Care Organizational Ethics. Special Report: Nurses at the Table: Nursing, Ethics, and Health Policy. The Hastings Center Report, 46(5), S39-S42. (PMID: 27649919). doi:10.1002/hast.63

  • Naylor, M.D., Hirschman, K.B., Hanlon, A.L., Abbott, K.M., Bowles, K.H., Foust, J., …, Zubritsky, C. (2016). Factors associated with changes in perceived quality of life among elderly recipients of long term services and supports. Journal of the American Medical Directors Association,17(1), 44-52. (PMID: 26412018; PMCID: PMC4696886. doi:10.1016/j.jamda.2015.07.019.

  • Naylor, M.D., Kurtzman, E.T., Miller, E.A., Nadash, P., & Fitzgerald, P. (2015). An assessment of state-led reform of long-term services and supports. Journal of Health Politics, Policy and Law , 40(3), 531-574. (PMID: 25700376). doi:10.1215/03616878-2888460

  • 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, (PMID: 26882510). doi:10.3912/OJIN.Vol20No03Man01

  • Toles, M., Moriarty, H., Coburn, K., Marcantonio, S., Hanlon, A., Mauer, E., … Naylor, M.D. (2015). Managing chronic illness: Nursing contact and participant enrollment in a Medicare care coordination demonstration program. Journal of Applied Gerontology, published online 8/31/2015. doi:10.1177/0733464815602115

  • Lamb, G., Newhouse, R., Beverly, C., Toney, D.A., Cropley, S., Naylor, M., … Task Force Members. (2015). Policy agenda for nurse-led care coordination. Nursing Outlook, 63(4), 521-530.

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