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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

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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.

Latest Resources

Keep up-to-date with the latest news, publications and reports. Read more
  • Update: COVID-19 Pandemic-Associated Changes in Emergency Department Visits—Unites States, December 2020-January 2021 (MMWR, April 16, 2021)
  • Latest Data on COVID-19 Vaccinations Race/Ethnicity (KFF, April 7, 2021)
  • Symptoms of Anxiety or Depressive Disorder and Use of Mental Health Care Among Adults During the COVID-19 Pandemic — United States, August 2020–February 2021 (MMWR, April 2, 2021)
  • ‘It Takes Time’: I.C.U. Workers Help Their Former Covid Patients Mend (NYT, April 1, 2021)
  • Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study (BMJ, March 31, 2021)
  • Many ‘Long Covid’ Patients Had No Symptoms From Their Initial Infection (NYT, March 8, 2021)


QUICK Access TO COVID-19 information 


COVID-19 Hospitalization and Death by Race/Ethnicity

Long-Term Effects of COVID-19


Coronavirus disease (COVID-19) pandemic


Emerging Stronger After COVID-19