Coordinating Care Between Hospital and Home: Translating Research into Practice, Phase 1


Discontinuity in care for patients discharged from hospitals significantly compromises quality of care. Elderly patients with multiple chronic conditions are particularly vulnerable. A multidisciplinary research team based at the University of Pennsylvania School of Nursing has developed and tested in controlled trials an innovative model of care coordination delivered by advanced practice nurses to high-risk older adults who are making the difficult transition from hospital to home. This project will translate the research into practice at a major health care insurer, Aetna. During Phase 1, the investigators will: 1) convert assessment tools and intervention protocols into Web-based modules that could be used by any insurer, including Medicare, to implement the model; 2) develop clinical information systems, marketing tools, and educational materials for insurers and providers; and 3) test and evaluate the model's effectiveness and economic feasibility in preparation for large-scale implementation in Phase 2. If the model is successful, it would generate cost savings for providers and insurers and enhance quality through better coordination of care.

Grant Details

Grantee Organization:
University of Pennsylvania
Principal Investigator:
Mary D. Naylor, Ph.D., R.N., F.A.A.N.
Award Amount:
Approval Date:
November 11, 2003

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