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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.
  • 1,300 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 650 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 spoke with Eileen Brinker, Clinical Coordinator for the MIRROR-TCM trial based in the Office of Population Health and Accountable Care at UCSF Health, to discuss the complex health and social needs patients experience and the importance of care continuity in meeting those needs through engagement, communication, education, and the strength of a well-built team.

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Latest Resources

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

  • Smulowitz et al. discuss trends in ED visits, admissions, and mortality in Medicare patients nationally during the COVID-19 pandemic. Decreases in ED visits were largest in April of 2020. The authors also describe the generally constant admission rates for serious illnesses combined with increased mortality rates, representing the admission of higher-acuity patients, which could be attributed to delays in seeking medical care. National Trends In ED Visits, Hospital Admissions, And Mortality For Medicare Patients During The COVID-19 Pandemic (Health Affairs, September 2021)
  • Hick et al. discuss standards of care during the pandemic. The report highlights the importance of equity, surge planning, and clinical decision-making. Crisis Standards of Care and COVID-19: What Did We Learn? How Do We Ensure Equity? What Should We Do? (National Academy of Medicine, August 30, 2021)