Transitional Care + Medical Home = Innovation

The first Hillman Innovation grant is helping to underwrite the work of Mary Naylor, PhD, FAAN, RN, Marian S. Ware Professor in Gerontology at the University of Pennsylvania’s School of Nursing. Dr. Naylor is one of the nation’s leaders in developing interventions to improve care transitions, particularly for vulnerable older patients. Her Transitional Care Model (TCM)—which relies on a nurse practitioner and the active engagement of patients and their family caregivers to ensure safer transitions from hospital to home or other settings—is being implemented in health systems around the country.

With support from the Hillman Foundation, the Gordon and Betty Moore Foundation, and the Jonas Center for Nursing Excellence, Dr. Naylor and a multi-disciplinary research team at Penn will partner with small and large primary-care practices in southeastern Pennsylvania. Together, they will conduct a large-scale study comparing the effects of a Patient-Centered Medical Home (PCMH), an increasingly popular model of coordinated primary care, with a new model that combines PCMH with Naylor’s TCM. Both ends of the study will focus on the same population: high-risk older adults coping with multiple co-existing conditions and their family caregivers.

This comparative effectiveness research, the first of its kind looking at evidence-based care coordination models, will see if the hybrid PCMH-TCM model can address one of the main system challenges facing medical homes. Today, primary-care practices (with medical homes or without) often confront a “wall of silence” when their patients enter the hospital. Many health care providers don’t even know that patients have been hospitalized until the patients arrive for their post-discharge follow-up visits. Even then, the quality of information about patients’ experience of care throughout an acute-illness episode is generally poor.

Integrating TCM, and its active engagement of patients and family caregivers, may provide a way to continue to monitor and intervene on behalf of high-risk patients throughout the chronic-illness trajectory and across settings, and potentially strengthen and lengthen the impact of the care-coordination benefits associated with a PCMH.