High-value transitional care: translation of research into practice


  • Funding: The Commonwealth Fund, and Jacob and Valeria Langeloth Foundation.

Dr Mary D. Naylor NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing 418 Curie Boulevard Claire M. Fagin Hall Room 341 Philadelphia, PA 19104-4217 USA E-mail: naylor@nursing.upenn.edu


Objective  To evaluate the impact of translating into a large US health plan, the Transitional Care Model (TCM), an evidence-based approach to address the needs of chronically ill older adults throughout acute episodes of illness.

Methods  A prospective, quasi-experimental study of 172 at-risk Aetna Medicare Advantage members in the mid-Atlantic region who received the TCM. A baseline and post-intervention (average of 2 months) comparison of enrolees' health status and quality of life was conducted. Member and physician satisfaction were assessed within 1 month post intervention. Health resource utilization and cost outcomes were compared to a matched control group of Aetna members at multiple intervals through 1 year.

Results  Improvements in all health status and quality of life measures were observed post- intervention compared to pre-intervention. Among 155 stringently matched pairs, a significant decrease in number of re-hospitalizations (45 vs. 60, P < 0.041) and total hospital days (252 vs. 351, P < 0.032) were observed at 3 months. Reductions in other utilization outcomes or time points were not statistically significant. The TCM was associated with a short-term decrease of $439 per member per month in total health care costs at 3 months and cumulative per member savings of $2170 at 1 year (P < 0.037).

Conclusions  Findings demonstrate that a rigorously tested model of transitional care for chronically ill older adults can be successfully translated into a real-world organization and achieve higher value.