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

The MIRROR-TCM project is designed to evaluate the TCM in a large, multi-site demonstration with a Medicare population:

  • Nine hospitals from four health systems (Veterans Health Administration, Trinity Health, University of California San Francisco [UCSF] Health, and Providence Joseph Health-Swedish Health Services) located in five states have partnered with Penn to participate in the RCT.
  • 1,600 patients (400 from each health system) will be recruited to participate; 50% (800 total; 200 from each health system) will be randomly assigned to receive the TCM.

  • Major goals of this project are to promote system-wide uptake of the TCM by participating health systems and to change payment policies. 
  • The Penn team (led by Mary Naylor) will coordinate this initiative, providing all participating sites with training and other forms of technical assistance essential to implement the TCM with fidelity. The Penn team also will rigorously examine internal and external factors that may influence the implementation and, if successful, health systems’ spread of the TCM.
  • The Mathematica team (led by Dr. Randall Brown) will independently evaluate the outcomes achieved by this replication study.