The Transitional Care Model
for Older Adults
Mary D. Naylor, PhD, RN
Marian S. Ware Professor in Gerontology
Director, NEWCOURTLAND CENTER FOR TRANSITIONS AND HEALTH
University of Pennsylvania, School of Nursing
National Health Policy Forum
Washington, DC – April 3, 2009
Transitional Care
Transitional care – range of time limited
services that complement primary care and
are designed to ensure health care
continuity and avoid preventable poor
outcomes among at risk patient groups as
they move from one level of care to
another, among multiple providers and
across settings.
Context for Transitional Care:
Acute Care Episode
Adapted from the National Quality Forum committee on Measurement Framework: Evaluating Efficiency across Episodes of Care
Quality Cost
Transitional Care Model (TCM)
Engaging
Elder/Caregiver
Managing
Symptoms
Educating/
Promoting
Self-Management
Assuring
Continuity
Coordinating
Care
Maintaining
Relationship
Screening
Collaborating
5
Unique Features
Care is delivered and
coordinated
…by same TC nurse
…in hospitals, SNFs, and homes
…7 days per week/mean of 2 months
…using evidence-based protocol
…with focus on long term outcomes
Core Components
Holistic, person/family centered
approach
Protocol guided, streamlined care
Team model; shared accountability
Single “point person” across episode of
care
Information/communication systems
that span settings
7
Findings from Randomized
Clinical Trials To Date
Funding: National Institutes of Health, National Institute of
Nursing Research, National Institute on Aging (1990-2010)
8
Across all RCTs, TCM has…
Increased time to first readmission or
death
Improved physical function and quality
of life*
Increased patient satisfaction
Decreased total all-cause readmissions
Decreased total health care costs
*Most recently completed RCT only
1 Naylor MD, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, & Pauly MV. Comprehensive discharge planning for
the hospitalized elderly. Ann Intern Med. 1994;120:999-1006.
2 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 clinical trial. JAMA. 1999;281:613-620.
3 Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults
hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
10
* Total costs were calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician
visits, and care provided by visiting nurses and other healthcare personnel. Costs for TCM care is included in the
intervention group total.
** 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 clinical trial. JAMA. 1999;281:613-620.
*** Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults
hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
$6,661
$12,481
$3,630
$7,636
at
2
6
w
ee
ks
**
at
5
2
w
ee
ks
**
*
Dollars (US)
TCM's Impact on Total Health Care Costs*
TCM
Group
Control
Group
Translating TCM into Practice
Penn research team formed
partnerships with Aetna Corporation
and Kaiser Permanente to test “real
world” applications of research-based
model of care for high risk elders.
Funded by The Commonwealth Fund and the following
Foundations: Jacob and Valeria Langeloth, The John A.
Hartford, Inc., Gordon & Betty Moore, and California
HealthCare; guided by National Advisory Committee (NAC)
National Advisory Committee
VHA
Penn Home Care &
Hospice Services
http://www.aarp.org/
http://www.cms.hhs.gov/
http://www.ncqa.org/
http://www.medicarerights.org/index.html
http://www.pacificare.com/commonPortal/application;JSESSIONID_CP=LGCNcnyTV5FRdr29hk0r366Qz0SjkTJhdJGzfJLGzJCcdSkvMP7k!781660123!-549409331?namespace=pacificareGateway&origin=pacificareHeader.jsp&event=link.start
http://pennhealth.com/
Tools of Translation
Patient screening and recruitment
Web-based modules to orient nurses
Documentation and quality monitoring
via clinical information system (CIS)
Quality improvement (case conferences
and CIS)
Evaluation
Value =
Health Resource
Utilization/Costs
Environment: Ongoing chronic care management
programs.
Question: Does the Transitional Care Model offer
greater value in this environment?
Quality/Satisfaction
15
Progress to Date
Aetna – identified as “high value”
proposition; expansion proposed as part
of Aetna’s 2009 Strategic Plan
Kaiser – data collection/analyses
ongoing
University of Pennsylvania Health
System – adopted TCM (Blue Cross
reimbursing)
QIOs – working w/States to implement
TCM
16
Barriers to Wide Scale Adoption
Organization of current care system
Regulatory issues
Lack of quality and financial incentives
Challenges current “practice culture”
Acknowledgements
Research team, nurses and staff
NewCourtland Center for Transitions
and Health
Translation Partners
Funders
www.transitionalcare.info
Thank You!
Slide Number 1
Transitional Care
Context for Transitional Care:�Acute Care Episode
Quality Cost �Transitional Care Model (TCM)
Slide Number 5
Core Components
Findings from Randomized Clinical Trials To Date
Across all RCTs, TCM has…
Slide Number 9
Slide Number 10
Translating TCM into Practice
Slide Number 12
Tools of Translation
Value =
Progress to Date
Barriers to Wide Scale Adoption
Slide Number 17
Slide Number 18
Acknowledgements
Thank You!
