Journal of Gerontological Nursing

Spotlight 

The 2015 Doris Schwartz Gerontological Nursing Research Award: Mary D. Naylor, PhD, RN, FAAN—Transitional Care Model: A Journey from Evidence to Impact

Pamela Z. Cacchione, PhD, RN, CRNP, BC, FGSA, FAAN

Abstract

With brilliance, razor-sharp focus, tremendous grace, and humor, Dr. Naylor has transformed how we address the care of older adults across the continuum of care. As the chief architect of the Transitional Care Model (TCM), she has influenced health care delivery and national health care policy and positioned gerontological nurses at the forefront of health care redesign. Dr. Naylor and her multidisciplinary team at the University of Pennsylvania School of Nursing (Penn Nursing) have demonstrated that the TCM improves quality and cost, and most importantly, patient outcomes and experience with care. An internationally recognized leader in transitional care and gerontological nursing, her nursing career began in the Philadelphia area; she earned her BSN from Villanova University College of Nursing and her MSN and PhD from the University of Pennsylvania. As the Director of the NewCourtland Center for Transitions and Health, and the Marian Ware Professor in Gerontology at Penn Nursing, she has mentored and collaborated with many of the next generation of nursing scholars from BSN, MSN, PhD to Postdoctorate Fellows. Through the National Institute of Nursing Research–funded Ruth L. Kirschstein National Research Service Award (NRSA) training program in Individualized Care for At-Risk Older Adults (T32NR009356), Dr. Naylor and Dr. Kathryn Bowles are leading predoctoral students and postdoctoral fellows to understand the important role of nurses in shaping health care delivery now and for the future. Dr. Bowles, a former mentee and long-time colleague and collaborator, introduced Dr. Naylor on this special occasion. Dr. Naylor shared her ongoing journey from evidence to impact with the Gerontological Society of America's Nursing Interest Group at their Annual Conference last November. Below are some excerpts from her dynamic presentation as the recipient of the 2015 Doris Schwartz Gerontological Nursing Research Award.

Dr. Naylor started her presentation by discussing the development and testing of the TCM. She recalled how it was not a solitary endeavor, that many funding agencies, community partners, and treasured colleagues were instrumental in the path toward generating new knowledge. Early TCM studies examined the care of cardiac patients challenged by frequent readmission following a cardiac event. Dr. Naylor quickly uncovered this was not unique for cardiac patients alone, but all patients trying to manage multiple chronic conditions. Dr. Naylor knew at that time there had to be a better way.

Mary D. Naylor, PhD, RN, FAAN. Photo courtesy of M. Naylor.

Transitional care was envisioned as time-limited services designed to ensure health care continuity and avoid preventable poor outcomes among at-risk populations as they move from one level of care to another, among multiple team members and across settings, such as hospital to home (Coleman & Boult, 2003). The attention on prevention of poor outcomes focused on the high rates of patient safety and medical errors during transitions in care, the high number of serious unmet patient and family needs, and the high human toll that occurs during health care transitions. To address these serious concerns, the development and testing of the TCM began. The main components of the TCM include: assuring continuity, coordinating care, maintaining relationships, screening, engaging older adults and their families, managing symptoms, collaborating with providers, and educating and promoting self-care management (Hirschman, Shaid, McCauley, Pauly, & Naylor, 2015). Dr. Naylor is a champion for advanced practice nurses (APNs) and distinguishes the TCM from other care models by its use of a nurse-led, interdisciplinary team including patients and family caregivers. APNs follow patients from the hospital to skilled nursing facilities and to patients' homes, using evidence-based protocols with a focus on longer-term value.

The TCM has an impressive track record of demonstrating improved outcomes of chronically ill…

With brilliance, razor-sharp focus, tremendous grace, and humor, Dr. Naylor has transformed how we address the care of older adults across the continuum of care. As the chief architect of the Transitional Care Model (TCM), she has influenced health care delivery and national health care policy and positioned gerontological nurses at the forefront of health care redesign. Dr. Naylor and her multidisciplinary team at the University of Pennsylvania School of Nursing (Penn Nursing) have demonstrated that the TCM improves quality and cost, and most importantly, patient outcomes and experience with care. An internationally recognized leader in transitional care and gerontological nursing, her nursing career began in the Philadelphia area; she earned her BSN from Villanova University College of Nursing and her MSN and PhD from the University of Pennsylvania. As the Director of the NewCourtland Center for Transitions and Health, and the Marian Ware Professor in Gerontology at Penn Nursing, she has mentored and collaborated with many of the next generation of nursing scholars from BSN, MSN, PhD to Postdoctorate Fellows. Through the National Institute of Nursing Research–funded Ruth L. Kirschstein National Research Service Award (NRSA) training program in Individualized Care for At-Risk Older Adults (T32NR009356), Dr. Naylor and Dr. Kathryn Bowles are leading predoctoral students and postdoctoral fellows to understand the important role of nurses in shaping health care delivery now and for the future. Dr. Bowles, a former mentee and long-time colleague and collaborator, introduced Dr. Naylor on this special occasion. Dr. Naylor shared her ongoing journey from evidence to impact with the Gerontological Society of America's Nursing Interest Group at their Annual Conference last November. Below are some excerpts from her dynamic presentation as the recipient of the 2015 Doris Schwartz Gerontological Nursing Research Award.

It Does Take a Village

Dr. Naylor started her presentation by discussing the development and testing of the TCM. She recalled how it was not a solitary endeavor, that many funding agencies, community partners, and treasured colleagues were instrumental in the path toward generating new knowledge. Early TCM studies examined the care of cardiac patients challenged by frequent readmission following a cardiac event. Dr. Naylor quickly uncovered this was not unique for cardiac patients alone, but all patients trying to manage multiple chronic conditions. Dr. Naylor knew at that time there had to be a better way.


Mary D. Naylor, PhD, RN, FAAN
Photo courtesy of M. Naylor

Mary D. Naylor, PhD, RN, FAAN. Photo courtesy of M. Naylor.

Why “Transitional Care?”

Transitional care was envisioned as time-limited services designed to ensure health care continuity and avoid preventable poor outcomes among at-risk populations as they move from one level of care to another, among multiple team members and across settings, such as hospital to home (Coleman & Boult, 2003). The attention on prevention of poor outcomes focused on the high rates of patient safety and medical errors during transitions in care, the high number of serious unmet patient and family needs, and the high human toll that occurs during health care transitions. To address these serious concerns, the development and testing of the TCM began. The main components of the TCM include: assuring continuity, coordinating care, maintaining relationships, screening, engaging older adults and their families, managing symptoms, collaborating with providers, and educating and promoting self-care management (Hirschman, Shaid, McCauley, Pauly, & Naylor, 2015). Dr. Naylor is a champion for advanced practice nurses (APNs) and distinguishes the TCM from other care models by its use of a nurse-led, interdisciplinary team including patients and family caregivers. APNs follow patients from the hospital to skilled nursing facilities and to patients' homes, using evidence-based protocols with a focus on longer-term value.

The TCM has an impressive track record of demonstrating improved outcomes of chronically ill older adults with lower costs of health care (Naylor et al., 1994; Naylor et al., 1999; Naylor et al., 2004). To share with clinicians and providers what could be achieved by using the TCM, tools were developed to screen and engage patients; to prepare nurses, interdisciplinary teams, and health systems through live web-based seminars; to document and monitor efforts at both the patient and organizational levels; and lastly, to evaluate performance improvement processes. This was no easy undertaking, and Dr. Naylor and her team approached this systematically to ensure the triple aim of higher patient (and provider) satisfaction with the care experience and improved outcomes with lower costs.

Person-Centered Transitions

The evolution of the TCM model includes older adults, hospitalized and/or at increased risk of hospitalization along three trajectories. One trajectory has older adults returning to their previous health status or better in a stable course. The next trajectory addresses the instability of post-hospital stays requiring comprehensive post-hospital coordination. The last trajectory focuses on palliative or hospice services for patients nearing the end of life. Each trajectory presents its own set of TCM protocols and interventions that when applied reflect the preferences and goals identified by patients and their family caregivers. Dr. Naylor is currently testing the impact of the TCM when integrated within health systems using a population approach. The direction of health care is moving away from the hospital setting to more care being provided in the community; the TCM has the potential to address the health care needs of community-dwelling older adults with multiple chronic conditions by helping them avoid costly and risky hospitalizations.

In addition, the TCM has demonstrated in comparative effectiveness studies improved outcomes and lower costs compared to other evidence-based protocols (Naylor et al., 2014). The TCM has been tested and integrated into patient-centered medical homes (Naylor, Hirschman, O'Connor, Barg, & Pauly, 2013), and the TCM has been replicated with similar clinical and economic outcomes in diverse patient populations and across health care systems and communities (Naylor, 2015). In an ongoing study sponsored by the Robert Wood Johnson Foundation, Dr. Naylor and her team have partnered with the Stevens Institute of Technology to develop a program for provider and payers to simulate the effects of the TCM based on their organizational inputs.

Dr. Naylor ended her remarks with a challenge to all of us that there is so much more work to be done to address the ever changing health care needs of chronically ill older adults. She encouraged us to consider the growing number of at-risk older adults and engage them along with their families in a collaborative effort to understand their transitions in health and health care. In her typical fashion, Dr. Naylor humbly reminded us that the TCM is proof of committed teamwork, tireless champions, and the critical partnership with patients and their family caregivers. We can't wait to see what she and her team have up their sleeves next!

Not to end there, Dr. Naylor graciously shared some sage advice for nurse scientists hoping to move their science to the policy realm (personal communication, M.D. Naylor, October 2016). She had three recommendations:

(a) Actively seek opportunities to immerse yourself (even for a short time period) in the policy world via fellowships. I was fortunate to have a fellowship that enabled me to study health and social policy in many countries. This experience culminated in my work with the staff of the U.S. Senate Committee on Aging. This fellowship was transformative in shaping our team's program of research and explicit efforts to use our findings to inform policy. (b) Choose an environment (school and university), a mentor, and a research team committed to having an impact on both policy and practice. Penn has been an ideal fit for me. I have been blessed with mentors who understand and value my efforts to promote the use of evidence and team members who have been trailblazers determined to positively influence the care and outcomes of chronically ill older adults and their families. (c) Take advantage of every opportunity to shape future policy at local, state, and federal levels. My membership on several boards and commissions (e.g., MedPAC) have positioned me to promote the use of evidence-based solutions to address the major health and social challenges confronting the United States.

One of Dr. Naylor's incredible skill sets includes the ability to engage stakeholders. She strongly believes as stated earlier it does take a village (Naylor, 2015):

Successful engagement of key stakeholders is grounded in trusting relationships, nurtured in mutual respect, and sustained through a shared commitment to achieve something meaningful for patients, families, and communities. Establishing and nurturing these relationships requires considerable investment but the payoff is tremendous. A few ideas to engage multiple stakeholders in addressing critical problems: (a) Engage representatives of groups you want to influence early and often. Every research study our team conducts is guided from conceptualization through dissemination and translation by such an advisory group. (b) Position yourselves on groups where you have the opportunity to build relationships with key stakeholders. (c) Be a generous partner. When stakeholders reach out to you for investment in their work, step up to the plate. (d) Constantly acknowledge the contributions of stakeholders.

In the end, Dr. Naylor acknowledges this takes great effort, so taking care of one's self is critical. Her advice for taking care of yourself throughout your journey is to always put family and friends first: “There is absolutely no substitute for the wonderful personal relationships that bring unparalleled joy, ensuring that I maintain perspective and keep me focused on what really matters!”

References

  • Coleman, E.A. & Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51, 556–557. doi:10.1046/j.1532-5415.2003.51186.x [CrossRef]
  • Hirschman, K.B., Shaid, E., McCauley, K., Pauly, M.V. & Naylor, M.D. (2015). Continuity of care: The Transitional Care Model. The Online Journal of Issues in Nursing, 20, 1. doi:10.3912/OJIN.Vol20No03Man01 [CrossRef]
  • Naylor, M., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M. & Pauly, M. (1994). Comprehensive discharge planning for the hospitalized elderly: A randomized clinical trial. Annals of Internal Medicine, 120, 999–1006. doi:10.7326/0003-4819-120-12-199406150-00005 [CrossRef]
  • Naylor, M.D. (2015, November). Transitional care model: A journey from evidence to impact. Annual Doris Schwartz Award Lecture, Gerontological Society of America, Orlando, FL.
  • Naylor, M.D., Brooten, D., Campbell, R., Jacobsen, B.S., Mezey, M.D., Pauly, M.V. & Schwartz, J.S. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. Journal of the American Medical Association, 281, 613–620. doi:10.1001/jama.281.7.613 [CrossRef]
  • Naylor, M.D., Brooten, D.A., Campbell, R.L., Maislin, G., McCauley, K.M. & Schwartz, J.S. (2004). Transitional care of older adults hospitalized with heart failure: A randomized, controlled trial. Journal of the American Geriatric Society, 52, 675–684. doi:10.1111/j.1532-5415.2004.52202.x [CrossRef]
  • Naylor, M.D., Hirschman, K.B., Hanlon, A.L., Bowles, K.H., Bradway, C., McCauley, K.M. & Pauly, M.V. (2014). Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults. Journal of Comparative Effectiveness Research, 3, 245–257. doi:10.2217/cer.14.14 [CrossRef]
  • Naylor, M.D., Hirschman, K.B., O'Connor, M., Barg, R. & Pauly, M.V. (2013). Engaging older adults in their transitional care: What more needs to be done?Journal of Comparative Effectiveness Research, 2, 457–468. doi:10.2217/cer.13.58 [CrossRef]
Authors

Dr. Cacchione is Ralston House Endowed Term Chair in Gerontological Nursing, Associate Professor of Geropsychiatric Nursing, University of Pennsylvania, School of Nursing, Philadelphia, Pennsylvania.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Pamela Z. Cacchione, PhD, RN, CRNP, BC, FGSA, FAAN, Ralston House Endowed Term Chair in Gerontological Nursing, Associate Professor of Geropsychiatric Nursing, University of Pennsylvania, School of Nursing, 418 Curie Boulevard, Philadelphia, PA 19104-4217; e-mail: pamelaca@nursing.upenn.edu

10.3928/00989134-20161110-04

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