Translational and Implementation

The clinical and economic outcomes of TCM have been replicated in diverse health systems and communities. The success of these efforts requires both rigorously tested translation tools, and active partnership and commitment of local health systems and community leaders and staff as well as payers.


To extend the reach and improve the benefits derived from the TCM approach, we are examining adaptations of the TCM by local health systems and communities throughout the United States. While some health care settings and communities choose to adopt the TCM core components as tested, multiple factors may affect how other sites implement this evidence-based care management approach. Some TCM users have chosen to adapt one or more core components to reflect local customs and practices. Others may not have resources (e.g., EHRs) to effectively apply the TCM components. In the Local Adaptations of the Transitional Care Model study funded by the Robert Wood Johnson Foundation, we identified how health systems and communities are adapting common core components. Our team completed a national scan to identify how health care organizations are using evidence-based transitional care to redesign their care systems. Findings from this initial phase of our work reveal that about 60 percent of 582 respondents report using the TCM alone or in combination with other approaches. Read more…


University of Pennsylvania Health System

To determine if clinical and economic effects achieved in multi-site research projects could be replicated in “real world” health care systems, we partnered with the University of Pennsylvania Health System (UPHS) and a major health care insurer (Aetna). Findings demonstrated significant improvements in all assessed measures of health and quality of life among Medicare managed care members who received the TCM, plus telephonic case management, when compared to a similar patient group who received telephonic case management only. Among stringently matched pairs in this study, significant decreases in the total number of rehospitalizations and total hospital days were observed at 90 days. A significant reduction in total health care costs per member per month at 90 days and a cumulative per member savings of $2,170 at one year post-enrollment also were observed in the TCM intervention group, relative to the comparison group.

Based on this work, the UPHS launched the Transitional Care Program service line with support funding from major local health care insurers. To date (2009 through 2016), more than 800 high risk patients admitted to the UPHS have enrolled in this service line. The rehospitalization rate at 30 days is substantially below the national average for all cause rehospitalizations among Medicare beneficiaries (MedPAC, 2015) and is half that of the 30-day rehospitalization rate for Medicare beneficiaries with four or more chronic conditions (Lochner et al., 2013). Additionally, findings revealed that the positive impact on rehospitalizations has been sustained for patients through 90-days post index hospital discharge. Since February 2014, our team has been assessing the effects of ongoing monitoring and follow-up of this patient group through nine months post-index hospitalization.

Over time, our initial results indicate that TCM patients report fewer symptoms, less pain, and lower ratings of depressive symptoms and anxiety than similar, non-TCM patients, and improved quality of life, physical function, instrumental ADLs, and cognitive status.

The Business Case for Implementation

A Scan Foundation funded report provides a strong business case for plans and other risk holders to identify the highest risk beneficiaries and target care management programs that are proven to decrease that risk.

Avalere’s return on investment (ROI) analysis indicates that, for example, the Transitional Care Model, when targeted at high-risk beneficiaries, can yield an ROI of more than 250%. The savings, in fact, are equivalent to about $10 billion if the approach were implemented nationwide.


Naylor MD, Hirschman KB, Toles MP, Jarrin OF, Shaid E, Pauly MV. Adaptations of the evidence-based Transitional Care Model in the U.S. Soc Sci Med. 2018 Sep;213:28-36. Epub 2018 Jul 17.

Naylor MD, Bowles KH, McCauley KM, Maccoy MC, Maislin G, Pauly MV, Krakauer R. High-value transitional care: translation of research into practice. J Eval Clin Pract. 2013 Oct;19(5):727-33. doi: 10.1111/j.1365-2753.2011.01659.x. Epub 2011 Mar 16.

Naylor MD, Feldman PH, Keating S, Koren MJ, Kurtzman ET, Maccoy MC, Krakauer R. Translating Research into practice: transitional care for older adults. J Eval Clin Pract. 2009 Dec;15(6):11164-70. doi: 10.1111/j.1365-2753.2009.01308.x.