Hospital to Home

Three federally-funded randomized clinical trials found that TCM improves quality and cost outcomes for hospitalized older adults, when compared to standard care.

In each RCT, we refined the model and modified the length of the intervention to address the needs of increasingly complex groups of older adults with multiple chronic conditions.

Demonstrated outcomes include:

  • Reductions in preventable hospital readmissions for both primary and co-existing health conditions. Additionally, among patients who are rehospitalized, the interval between hospital discharge and readmission has been increased and the total number of inpatient days decreased.

  • Improvements in health outcomes and patient satisfaction. Patients receiving TCM report improvements in physical health and quality of life, as well as in overall satisfaction with care.

  • Reductions in total health care costs. TCM is not just cost-effective; it is cost-saving. In the year after discharge, Medicare saves an average of nearly $5,000 (2002) per person receiving TCM, after accounting for the cost of intervention itself.

Calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician visits, and care provided by visiting nurses and other health care personnel. Costs for TCM care are included in the intervention group total.


Naylor MD. Transitional care for older adults: a cost-effective model. LDI Issue Brief. 2004 Apr-May;9(6):1-4.

Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized clinical trial. J Am Geriatr Soc. 2004 May;52(5):675-684.

Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized controlled trial. JAMA. 1999 Feb 17;281(7):613-620.

Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly: a randomized clinical trial. Ann Intern Med. 1994 Jun 15;120(12):999-1006.