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Promising Program Expands to Address More Complex Care Patients

A nurse-led transitional care model is shown to have sizable cost and re-hospitalization reductions.

(Richard Bailey/Getty Images)

Nearly a quarter of Medicare beneficiaries 65 years and older have been diagnosed with heart failure or chronic obstructive pulmonary disease. Five percent are diagnosed annually with pneumonia. More than 80 percent have at least three other chronic conditions.

Within 30 days of hospital discharge, many of these patients will end up back in the hospital. And those re-hospitalizations make up a significant share of the $750 billion spent annually on Medicare.

This complicated, expensive problem is compounded by the dearth of proven programs that improve care and reduce costs. 

But a nurse-led hospital discharge and home follow-up program at the University of Pennsylvania is an exception. Two well-conducted randomized controlled trials (RCTs) of the approach, published in 1999 and 2004, found reductions in re-hospitalizations of up to 50 percent and net health care savings of about $4,500 per patient. The Transitional Care Model (TCM), developed by Mary Naylor and her team at the UPenn School of Nursing, is the only transitional care program with experimental evidence of sizable reductions in re-hospitalizations and net health care costs. Despite these promising findings, hospital system adoption of TCM has been slow and time-intensive.

In response, UPenn announced Wednesday, Arnold Ventures is granting $6 million to support the implementation and evaluation of TCM across nine hospitals that are part of four health systems — Swedish Health Services, Trinity Health, University of California San Francisco (UCSF) Health, and the Veterans Health Administration — in five states. UPenn and its partners will deliver TCM to a total of 800 patients and provide technical assistance to ensure implementation fidelity.

TCM is delivered by a master’s‑level transitional care nurse who works with the patient, his/​her family, and the patient’s doctor while the patient is hospitalized to develop an individualized plan of care. Following hospital discharge, the nurse accompanies the patient to the first physician visit and conducts an average of 12 home visits over three months to monitor symptoms and ensure the patient is taking prescribed medications.

Mathematica will conduct an RCT to determine whether the impacts found in the prior RCTs — particularly on hospital readmissions, health care costs, and patient quality of life — can be reproduced in health systems that are diverse in terms of geographic location, patient demographics, post-acute services offered, and hospital size. If effectively replicated, this trial would provide convincing evidence that TCM could be used in hospitals nationwide to improve patient health and generate health care savings.

The grant is part of Arnold Ventures’ Moving the Needle initiative, which aims to expand and replicate programs with credible experimental evidence of sizable impacts on important life outcomes.