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High-Value Transitional Care: Translation of Research into Practice

The Issue

Good transitional care provided to chronically ill elderly patients as they move from acute-care settings to their homes or to nursing facilities can lead to better health outcomes as well as reduced costs. This study tested the Transitional Care Model, which uses an advance practice nurse to coordinate care, among 172 patients enrolled in Aetna Medicare Advantage over an 18-month period.

What the Study Found

Comparing the health status of study participants before and after implementation of the Transitional Care Model, the researchers found significant improvement in functional status, depression, symptom status, self-reported health, and quality of life. Both patients and physicians interviewed reported a high level of satisfaction with the program. There was a significant reduction in hospital readmissions three months after enrollment, and a decrease in total health care costs of $439 per member per month.


A combination of factors—from the growing number of older adults with complex chronic conditions to the health reform law's emphasis on maximizing value in health care—makes transitional care of national importance, the authors say. They note, however, that without a methodology for reimbursing providers for such services, improvements like the Transitional Care Model are unlikely to be adopted widely.

Publication Details

Publication Date: April 27, 2011
Author: Mary D. Naylor, Ph.D., R.N., FAAN, Kathryn H. Bowles Ph.D., R.N., FAAN, Kathleen M. McCauley Ph.D., R.N., A.C.N.S.–B.C., FAAN, FAHA, Maureen C. Maccoy, R.N. M.B.A., Greg Maislin, M.S., M.A., Mark V. Pauly, Ph.D., and Randall Krakauer M.D., FACP, FACR
Summary Writer: Deborah Lorber
Citation: M. D. Naylor, K. H. Bowles, K. M. McCauley et al., "High-Value Transitional Care: Translation of Research into Practice," Journal of Evaluation in Clinical Practice, published online March 16, 2011.