Transitional Care Model: Translating Research Into Policy and Practice

Mary Naylor, PhD, RN, Professor of Gerontology; Director NewCourtland Center for Transitions & Health, School of Nursing, University of Pennsylvania

Nearly 20% of Medicare beneficiaries are readmitted within 30 days of hospital discharge--resulting in over $15 billion in annual costs. Yet, between 10 to 50% of readmissions are avoidable. Learn how the Transitional Care Model (TCM) targets the individual, family and system drivers of readmission and why it is being adopted by organizations including Aetna and Kaiser Permanente.

- Identify individual, family and system factors associated with poor post-discharge outcomes among hospitalized older adults.
- Describe TCM concepts and key findings from TCM testing.
- Describe the tools for supporting TCM translation and adoption.
- Describe how evidence from TCM testing informs clinical practice and health care policy

Dr. Naylor is the Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. Since 1989, Dr. Naylor has led an interdisciplinary program of research designed to improve the quality of care, decrease unnecessary hospitalizations, and reduce health care costs for vulnerable community-based elders. Dr. Naylor is also the National Program Director for the Robert Wood Johnson Foundation program, Interdisciplinary Nursing Quality Research Initiative. She was elected to the National Academy of Sciences, Institute of Medicine in 2005. She also is a member of the RAND Health Board, the National Quality Forum Board of Directors and chairs the Board of the Long Term Quality Alliance. She was recently appointed to the Medicare Payment Advisory Commission. Dr. Naylor received her MSN and PhD from the University of Pennsylvania and her B.S. in Nursing from Villanova University.