Translating Research into Practice: Transitional Care for Elders

Grant Summary

While the nation's health care system is desperately in need of innovations to improve the care of the increasing numbers of older Americans, bringing new models of care from research to routine practice can be difficult and time consuming. The Foundation approved a grant that will support the cost of implementing and feasibility testing of a transitional care model within the Kaiser health care system. Developed by Mary D. Naylor, PhD, RN, and her colleagues at the University of Pennsylvania, this nursing-based post-hospitalization model assigns a nurse to provide intensive case management and coordination of services as the patient returns home. Variations of the model will be tested at three sites within the Kaiser system to investigate the best use of advanced practice and registered nurse staff. The model, using advanced practice nurses, is currently being tested with the Aetna Medicare managed care plan with funds from the Commonwealth Fund and the Jacob and Valeria Langeloth Foundation. Observations from the project's advisory committee, that testing variants of the model using nurses without advanced practice degrees might increase interest among health care systems, led to this phase of the project.