Transitional Care Model

Mary Naylor
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The Transitional Care Model, designed by Mary Naylor, professor of gerontology and director of NewCourtland Center for Transitions and Health, and colleagues at the University of Pennsylvania, targets older adults with two or more risk factors, including a history of recent hospitalizations, multiple chronic conditions or medications and poor self-health ratings.

The model, although complementary to, is not care management, according to the researchers.

"The major goal of this model is to help the patient and family caregivers develop the knowledge, skills and resources essential to prevent future decline and rehospitalization," according to the Transitional Care Model website. "At the end of this episode of care, continuity is assured by excellent communication with the primary care providers continuing to follow patients who have made a commitment to their self-management goals."

Key to the model is the care coordinator called a "transitional care nurse," who ushers the patient through in-hospital planning and home follow-up. The role, which is different from traditional roles, incorporates the skills of a nurse, care manager and patient advocate, according to the website.

Within a day of enrollment in the program, the transitional care nurse assesses the patient's health status in the hospital. The transitional care nurse then visits the patient's home within 24 to 48 hours of discharge and then again once per week during the first month, followed by semi-monthly visits until discharge from the program, as well as offers phone support seven days a week. After the patient completes the program, the transitional care nurse prepares a summary for the patient and primary care provider and provides access to other care services, if needed.

U Penn's model, which partners with Aetna and Kaiser Permanente, cut readmissions by 28 percent within the first 24 weeks and by 13 percent within a year. It also has cut costs by 39 percent per patient, or nearly $5,000, within the year after hospitalization.

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