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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

This multi-site initiative is replicating the Transitional Care Model (TCM) in three health systems (Veterans Health Administration, Trinity Health, and University of California San Francisco [UCSF] Health) 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 six hospitals based in three health systems along with their community partners are collaborating with the Penn team led by Dr. Mary Naylor in this project.
  • 1,000+ 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 500+ older adults assigned to the intervention group and their family caregivers from hospital admission to an 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

We connected with Heidi Steinhebel, RN,BSN,CCM,CCP, Senior Associate Director of Care Management at IHA, and Clinical Coordinator for the MIRROR-TCM study at Trinity Health-Michigan. Steinhebel shares her thoughts on the importance of equitable access to care, communication and engagement, and meeting the needs of patients across the care continuum.

Read more

Latest Resources

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

  • Becker’s Hospital Review featured findings from Cohen et al, published in the British Medical Journal, almost a third of older adults develop new medical conditions after COVID-19. 

  • Graham dives into the ongoing shortage of home health workers leaving patients without needed care for Kaiser Health News, while families struggle to access care for their loved one.