Nurse-led approach helps cut costs, spur recovery

Caring for older patients living with complex health and social needs is one of the biggest challenges for the healthcare system. It’s a challenge that will continue to intensify as the baby boom generation ages.

Mary Naylor, director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, is the lead architect of the Transitional Care Model (TCM), a nurse-led approach designed to help improve the care of seniors coping with multiple chronic conditions who experience frequent episodes of acute illness. The goal is to partner with patients, family caregivers and other clinicians to improve the patient’s health and quality of life. Studies consistently show that this model helps lower hospital readmission rates and reduce per-patient healthcare costs.

“We’ve seen that the connection between this group of older adults and an advanced practice nurse who can help them manage their care is critical,” says Naylor, who is also an advisor to PreparedHealth. “We cannot ever lose the human touch with this population and we can work as a team to extend the reach of care.” Here’s what else she had to say:

Prepared Health: What are some of the challenges of caring for chronically ill, older patients?

Mary Naylor: Among the more than 20 million Medicare beneficiaries, 37 percent have five or more chronic conditions. Because of frequent illnesses, this group uses more—and more costly—resources, including physician visits, emergency room visits and hospitalizations, compared to all Medicare beneficiaries.

Many don’t need to be hospitalized but they do need other services. And their care can be complicated by other factors. They may have difficulties with everyday tasks such as walking or preparing food. They may suffer from depression. There may be behavioral health issues that are not identified or addressed, or they may be on way too many medications.

Unfortunately, studies show that the healthcare needs of this patient group are often poorly managed due to long-standing institutional issues like a lack of trust between older adults, caregivers and health care teams; limited preparation for self-care; poor communication and collaboration among team members; and gaps in access to health and community-based services.

What can healthcare providers do to better meet the needs of this group?

We’ve consistently seen better results from providers that have implemented the TCM, a hospital-to-home follow-up program for older adults who are at risk for poor outcomes as they move across healthcare settings and between clinicians. This model also has been shown to prevent hospitalizations among at-risk seniors living in the community. Led by nurses with advanced knowledge and skills in the care of this population, TCM is an individualized approach to designing and delivering care for people who need more assistance in achieving what matters to them. Not everyone who visits a primary care office or is admitted to a hospital is at risk for poor outcomes; correctly identifying the target population is essential to better deploy our finite resources.

The goal of transitional care is to enable older adults to make decisions about their care, prevent unnecessary health complications, support family caregivers and reduce the use of avoidable costly services. We want to interrupt what has been happening and make sure patients have consistent care including access to medications, a treatment plan they can participate in and adhere to, and someone to call if they run into trouble.

How does the TCM work?

If the model begins in the hospital, a trained nurse conducts a comprehensive assessment of the senior’s health status, behaviors, and level of social support and health goals. Working with the older adult and their healthcare team, the nurse coordinates a discharge and home follow-up plan and begins to engage and educate the patient and caregiver around health issues and goals. While in the hospital, the nurse visits the patient daily, with a focus on optimizing health at discharge.

There is an initial home visit (or visit to a skilled nursing facility) by the same nurse within 24 hours of hospital discharge, followed by weekly home visits for the first month. The nurse also attends the first physician visit post-hospital discharge. He or she follows the patient for an average of two months in an intensive way, during what is often a very vulnerable time. By going into a patient’s home, the nurse can extend the walls of primary care and continue to work to improve outcomes. When you get people feeling better, you reduce the need for acute care services. Better management early on and anticipating future needs are core elements of the TCM.

What results can you report?

In addition to positioning older adults and their caregivers to meet their needs and goals, a major goal of the TCM is to bring down the high rates of avoidable readmissions in both the short (30 or 90 days) and long term. In multiple NIH-funded clinical trials, the TCM has consistently demonstrated improvements in older adults’ functional status and quality of life and reduced total costs of care.

For example, two NIH-funded clinical trials showed a 30 percent to 50 percent reduction in re-hospitalization rates, and a savings of $3,000 to $5,000 per patient over six to 12 months following the index hospital discharge, among older adults who were part of the TCM, compared to those who received standard care.2 In a national survey of 580 health systems, 59 percent reported using a transitional care model as basis for redesigning care.1

How does Dina fit into the model?

Care fragmentation is the number one issue this group of seniors confronts. Dina (a HIPAA-compliant network that connects care providers and allows them to share patient updates) is an extraordinary tool to help people remain in contact with their healthcare team and to feel that there is a continuity of care as they move between healthcare professionals and across care settings. We also know that you cannot affect care unless you’re working together with the older adults’ network of family caregivers. Dina creates an opportunity for everyone on the healthcare team, including patients and their caregivers, to connect, prioritize issues and needs, design a plan of care, and identify needed community-based resources. I believe Dina represents an exciting, important and timely opportunity to extend the reach of care, enhance its effectiveness and improve the outcomes of older adults.

Author bio:

Mary Naylor is a professor and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing. She is a pioneer in the design, evaluation and spread of healthcare innovations that have both reduced healthcare costs and significantly improved the outcomes of chronically ill, older adults and their family caregivers. In collaboration with a multidisciplinary team of clinical scholars and health services researchers, her work has resulted in the Transitional Care Model, an advanced practice nurse-led model designed to improve the outcomes of older adults who are navigating complex and often fragmented systems of care. Naylor also is an advisor to PreparedHealth, a Chicago-based company that leverages technology and data to optimize care and improve outcomes for patients.



1Naylor,Mary D., K. Hirschmana, M. Toles, O. Jarrín, E. Shaid, M. Pauly. “Adaptations of the evidence-based Transitional Care Model in the U.S.” Social Science and Medicine, 2018, vol. 213, pp. 28-36.

2“Evidence Summary for the Transitional Care Model” Laura and John Arnold Foundation: Social Programs That Work ReviewUpdated Nov 2017


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