Mainstreaming a Model of Transitional Care for Chronically Ill Patients

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<p>Once a health care innovation has been proven effective, how does it come to be adopted by providers outside of clinical trials? </p>
<p>In the new Commonwealth Fund issue brief, <a href="/publications/issue-briefs/2010/nov/scaling-bringing-transitional-care-model-mainstream">Scaling Up: Bringing the Transitional Care Model into the Mainstream</a>, University of Pennsylvania School of Nursing researchers Mary Naylor, Ph.D., R.N., and Julie Sochalski, Ph.D., R.N., demonstrate how a highly effective innovation in care management for elderly, chronically ill people has begun to make the difficult leap from bench to bedside. </p>
<p>Because many elderly, chronically ill people undergo frequent changes in their health status, they also experience frequent transitions in health care providers and care settings. As demonstrated in multiple trials funded by the National Institutes of Health, the Transitional Care Model (TCM), developed by a team at the University of Pennsylvania, uses both in-person contact and a nurse-led, interdisciplinary team approach to interrupt patterns of frequent rehospitalizations seen among chronically ill patients. It has also been shown to improve patient health status and reduce costs. </p>
<p>In their brief, Naylor and Sochalski describe two projects that identified the essential elements of effective care management interventions for this vulnerable population and the facilitators of translating the TCM into mainstream practice. The authors say that to become part of mainstream practice, much more than evidence is required. "Fundamental changes are needed in the structures, care processes, and roles assumed by health professionals and their relationships to each other and the patients they serve," they write.</p>