Accreditation Announcement >>

Skip to main content


Expansion and evaluation of the Transitional Care Model to improve health outcomes, reduce costly rehospitalizations, and encourage widespread use of this evidence-based program

  • <a href="/live/image/gid/60/width/650/11218_SS_Swedish.png" class="lw_preview_image lw_disable_preview" tabindex="-1"><img src="/live/image/gid/60/width/814/height/172/11218_SS_Swedish.rev.1603113306.png" alt="" class="lw_image lw_image11218" width="814" height="172" data-max-w="814" data-max-h="172"/></a>
  • <a href="/live/image/gid/60/width/650/11217_SS_VHA.png" class="lw_preview_image lw_disable_preview" tabindex="-1"><img src="/live/image/gid/60/width/814/height/172/11217_SS_VHA.rev.1603113305.png" alt="" class="lw_image lw_image11217" width="814" height="172" data-max-w="694" data-max-h="235"/></a>
  • <a href="/live/image/gid/60/width/650/11216_SS_Trinity.png" class="lw_preview_image lw_disable_preview" tabindex="-1"><img src="/live/image/gid/60/width/814/height/172/11216_SS_Trinity.rev.1603113305.png" alt="" class="lw_image lw_image11216" width="814" height="172" data-max-w="836" data-max-h="194"/></a>
  • <a href="/live/image/gid/60/width/650/11215_SS_UCSF.png" class="lw_preview_image lw_disable_preview" tabindex="-1"><img src="/live/image/gid/60/width/814/height/172/11215_SS_UCSF.rev.1603113304.png" alt="" class="lw_image lw_image11215" width="814" height="172" data-max-w="789" data-max-h="165"/></a>

This multi-site initiative is replicating the Transitional Care Model (TCM) in four health systems (Veterans Health Administration, Trinity Health, University of California San Francisco [UCSF] Health, and Providence Joseph Health-Swedish Health Services [Swedish]) and rigorously examining patient and cost outcomes. The TCM is an advanced practice registered nurse (APRN) led, team-based intervention developed at Penn and proven in multiple NINR/NIA funded randomized clinical trials (RCTs) to improve health outcomes and reduce costs of care for at risk older adults transitioning from hospital to home. 

Project highlights

  • Clinicians, staff and leaders at nine hospitals based in four health systems, along with their community partners, are collaborating with the Penn team led by Dr. Mary Naylor in this project.
  • 1,600 hospitalized older adults with complex health and social needs are being recruited to participate in a RCT that is being conducted over three years.
  • APRNs will deliver the TCM protocol to 800 older adults assigned to the intervention group and their family caregivers from hospital admission to average of two months post-hospitalization.
  • A team at Mathematica led by Dr. Randall Brown will independently evaluate outcomes.

If successful in replicating outcomes demonstrated in NIH funded clinical trials, participating systems have expressed commitment to scale the TCM in their respective organizations. Study findings also will provide an actionable path for CMS and other payers to reduce healthcare costs among Medicare beneficiaries while maintaining high quality care.

The Penn team is rigorously examining challenges in implementing this innovative care management approach in the context of COVID-19 and assisting partners to implement the TCM with fidelity.

The In Focus series features conversations with leaders from participating health systems.The In Focus series features conversations with leaders from participating health systems.

Partner Spotlight

This month we spoke with Bela Biro, Executive Director of Accountable Care Services at Swedish Medical Group, to discuss the impact COVID-19 has had on meeting the challenges of of older adults coping with complex health and social needs in the Seattle community and the launch of the TCM within this health system.

Read more

Latest Resources

Keep up-to-date with the latest news, publications and reports. Read more

  • Readmission and death after initial hospital discharge among patients with COVID-19 in a large multihospital system (JAMA, December 14, 2020)
  • Household transmission of SARS-CoV-2: A systematic review and meta-analysis (JAMA Netw Open, December 14, 2020)
  • Characteristics of hospitalized COVID-19 patients discharged and experiencing same-hospital readmission—United States, March-August 2020 (MMWR, November 13, 2020)