Coordinating Care Between Hospital and Home: Translating Research into Practice, Phase 2


Nearly two decades of research have shown that having advanced practice nurses coordinate the care provided to extremely frail older adults following their discharge from the hospital significantly reduces the need for subsequent readmission. To promote adoption of this model of care coordination, a research team at the University of Pennsylvania is collaborating with the Aetna Corporation to devise a workable program for patients enrolled in managed care. With support from the Fund and the Jacob and Valeria Langeloth Foundation, the research team laid the groundwork for implementing the advanced practice nurse model in Phase 1. In Phase 2, project staff will test the model's impact on clinical outcomes, costs, and patient satisfaction in a portion of Aetna's Mid-Atlantic market. If the intervention proves successful, Aetna will consider offering the service as a defined benefit. Project findings, which will be shared with other insurers, could also inform the development of a transitional care benefit for Medicare or Medicaid.

Grant Details

Grantee Organization:
University of Pennsylvania
Principal Investigator:
Mary D. Naylor, Ph.D., R.N., F.A.A.N.
Award Amount:
Approval Date:
April 12, 2005

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