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Better science to support better outcomes

Clinical trials and comparative effectiveness studies have consistently demonstrated the TCM’s health and economic benefits, including reduced re-hospitalization and health care expenditures. Having established a solid knowledge base for the TCM in at-risk hospitalized elderly patients, the Penn team has adapted the model to include other settings and other populations. Working with nurses, physicians, health systems leaders, payers, and policymakers, the team has tested complex interventions and fostered quality and financial incentives to implement the model.

Latest Study

The MIRROR-TCM initiative funded by Arnold Ventures, the Missouri Foundation for Health and VA HSR&D is replicating and rigorously examining implementation of the Transitional Care Model (TCM) in three U.S. health care systems:  University of California San Francisco (UCSF) Health, Trinity Health, and the Veterans Health Administration. Together, these systems will recruit 1,000+ Medicare patients to participate in this RCT. Mathematica will conduct an  independent evaluation. 

Learn more about MIRROR-TCM