Transitional Care: A Critical Dimension of the Home Healthcare Quality Agenda


  • Mary D. Naylor

    Corresponding authorSearch for more papers by this author
    • Mary D. Naylor, PhD RN FAAN, is the Marian S. Ware Professor of Gerontology at the University of Pennsylvania School of Nursing and a senior fellow of the Leonard Davis Institute of Health Economics. Since 1989 Naylor and her interdisciplinary research team have completed three National Institute of Nursing Research-funded randomized clinical trials focusing on discharge planning and home follow-up of high-risk hospitalized elders by advanced practice nurses. An ongoing clinical trial funded by the Marian S. Ware Alzheimer Program and the National Institute on Aging (1R01AG023116–01A1) is testing innovative care coordination interventions aimed at improving outcomes for hospitalized cognitively impaired elders and their caregivers.


Abstract: Focusing on the critical transitions of patients and their caregivers across healthcare settings and among providers is a promising approach to enhancing care coordination and improving quality. This article describes the research base for the transitional care of older adults and offers recommendations to advance the science, translate best practices into home healthcare settings, and improve the transitions of high-risk older adults to and from home healthcare. Home healthcare is a component of the healthcare industry uniquely positioned to improve transitional care and outcomes for the growing population of older adults with continuous complex needs.