What is Transitional Care and Why Does It Matter to the Nation?

By Mary D. Naylor, PhD, RN, FAAN

Marian S. Ware Professor in Gerontology
Director, NewCourtland Center for Transitions and Health
University of Pennsylvania, School of Nursing

President Obama and Congress have both called for dramatic changes to how we deliver care in this country. With the aim of reducing costs, improving quality, and expanding coverage, legislators are calling for rapid innovation and real solutions. While many approaches are being considered, there is one approach on which many stakeholders have coalesced – the promise of transitional care for the chronically ill, elderly population. In fact, transitional care should be a cornerstone to American health care and a central component to these reform discussions.

Transitional care includes a broad range of time limited services designed to ensure health care continuity, avoid preventable poor outcomes among at risk populations, and promote the safe and timely transfer of patients from one level of care to another or from one setting to another. Transitional care is founded on effective communication and information transfer between the patient, family caregivers, and all health care providers involved in their care, dedicated post-discharge follow-up, and consistent and ongoing care throughout acute episodes of care from a single provider with specialized preparation in the care of people with multiple, chronic conditions who face the greatest risk for avoidable hospital admissions and poor outcomes.

Transitional care makes sense on its face, and the evidence backs this up. Nearly two decades of NIH supported research conducted by a multidisciplinary team at the University of Pennsylvania demonstrates that the Transitional Care Model (TCM) achieves the very aims that the Administration seeks to resolve—reduced costs, improved health care outcomes, and enhanced satisfaction of consumers, families, and providers. In fact, in the most recent National Institute of Nursing Research (NINR)-funded randomized controlled clinical trial reported to date, the TCM demonstrated savings of nearly $5,000 in total care costs per patient to Medicare and significant reductions in readmission rates up to one year after hospital discharge compared to routine follow-up care.

At the heart of TCM is a transitional care nurse (TCN), a master's prepared nurse with advanced knowledge and skills in the care of the chronically ill, older adults and their family caregivers, who provides regular hospital and home visits, 7 day per week telephone availability, and serves as the primary coordinator of care as patients transition from the hospital to home. The focus of TCM is to interrupt the cycle of repeated hospitalizations common among this population and achieve longer term positive outcomes

Why should TCM matter to the nation?
1. Today’s population is both older and more chronically ill than at any other point in our nation’s history, a trend projected to continue. This will place significant demands on our health care delivery and financing system that can be addressed, at least in part, by transitional care.
2. Family caregivers, spouses, children and friends who are the primary providers of services to these elders, also face tremendous challenges (e.g., lack of knowledge and skills, burden and stress)—challenges that can be mitigated by the TCM.
3. Chronically ill, elderly patients face high rates of rehospitalization—a "churning" which costs the American taxpayer $15 billion annually in Medicare spending and businesses $34 billion in losses each year due to employees' need to care for loved ones. TCM is a proven approach to care that addresses these important financial and societal problems.

For more information about TCM visit http://www.transitionalcare.info/.

Editor's note: Mary Naylor’s Transitional Care Model was featured on NPR’s Morning Edition for Tuesday, July 28, 2009.