CELEBRATING THIRTY YEARS OF AGING
AND HEALTH 2012 ANNUAL REPORT
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INNOVATIVE MODELS OF CARE

1983

Translating Research into Practice: Transitional Care for Elders

2006-2009 A multidisciplinary team led by Mary D. Naylor, PhD, RN, at the University of Pennsylvania developed a transitional care model to help older adults with multiple chronic conditions and health risks to successfully transition from acute care into the home or other less intensive care settings. Eligible hospitalized patients are assigned a transitional care nurse, who provides intensive case management and coordination of services.

The Hartford Foundation provided a grant of close to $500,000 to support the cost of implementing and testing the feasibility of this transitional care model within the Kaiser health care system.

Findings from three NIH-funded studies have shown that the Transitional Care Model reduces hospital readmissions, inpatient days, and health care costs. It was also shown to improve patient safety and physical function. Transitional Care Nurses also reported high job satisfaction.

The Hartford Foundation has contributed to advances in health care and health policy largely through its unbelievable investment in people who care passionately about older adults, their families, and their communities.” Mary D. Naylor, PhD, RN
Marian S. Ware Professor in Gerontology
Director
New Courtland Center for Transitions and Health
School of Nursing
University of Pennsylvania

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