Grant Recipient: University of Pennsylvania (Penn)
Term: 2020 – 2023
Summary: The Transitional Care Model (TCM) is a nurse-led hospital discharge and home follow-up program for chronically ill older adults, aimed at preventing health complications and re-hospitalizations. TCM is delivered by Master’s level transitional care nurses who work with older adults, their families, doctors and other health team members while older adults are hospitalized to develop individualized plans of care and, following discharge, accompany older adults to their physician visits and conduct an average of 12 home visits over three months to monitor symptoms and ensure the patient is taking medications. TCM is backed by uniquely promising evidence of sizable reductions in rehospitalizations and net healthcare costs. Two well-conducted RCTs in Philadelphia, published in 1999 and 2004, found reductions in rehospitalizations of 30-50%, and net healthcare cost savings of approximately $4,500 per patient, within 5-12 months after patient discharge.
Mary Naylor, the developer of TCM at Penn, will partner with four health systems (including nine hospitals) that serve diverse populations in five states – Washington, Michigan, California, Missouri, and Ohio. Penn and its partners will deliver TCM to a total of 800 patients. The cost per patient will be approximately $3,400, which includes start-up and other costs unique to a demonstration (the steady-state cost of TCM is about $1,200 per patient). The grant will also fund technical assistance to ensure faithful TCM replication, an assessment of implementation fidelity at each site, and recruitment of a sample of patients for the randomized controlled trial (RCT) evaluation of the project conducted by Mathematica. This RCT will determine whether the impacts found in prior RCTs can be reproduced under expanded implementation conditions in health systems that are diverse in terms of geographic location, patient demographics, post-acute services offered, and hospital size.