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High-value transitional care: translation of research into practice.
Mary D Naylor1, Kathryn H Bowles, Kathleen M McCauley
1Marian S. Ware Professor in Gerontology, Director, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA Associate Professor Associate Dean for Academic Programs, University of Pennsylvania School of Nursing, Philadelphia, PA, USA Nurse Director, Retiree Markets Head of Medicare Medical Management, Aetna, Inc., Princeton, NJ, USA Principal Biostatistician, Biomedical Statistical Consulting, Wynnewood, PA, USA Bendheim Professor and Professor of Health Care Management, University of Pennsylvania Wharton School, Philadelphia, PA, USA.
The Transitional Care Model (TCM) successfully improved health for chronically ill older adults in a large health plan. This evidence-based approach reduced hospitalizations and healthcare costs, demonstrating its real-world value.
Area of Science:
- Geriatric Medicine
- Health Services Research
- Translational Science
Background:
- Chronically ill older adults face significant challenges during acute illness episodes.
- Effective transitional care models are needed to manage this population and improve outcomes.
- The Transitional Care Model (TCM) is an evidence-based approach with proven benefits.
Purpose of the Study:
- To evaluate the successful translation and impact of the TCM within a large US health plan.
- To assess the TCM's effect on health status, quality of life, and healthcare utilization for at-risk Medicare Advantage members.
- To determine the cost-effectiveness of implementing the TCM in a real-world setting.
Main Methods:
- A prospective, quasi-experimental study involving 172 at-risk Aetna Medicare Advantage members receiving the TCM.
- Comparison of health status and quality of life pre- and post-intervention (2 months).
- Analysis of health resource utilization and costs against a matched control group over 1 year.
Main Results:
- Significant improvements in health status and quality of life measures post-intervention.
- A notable decrease in re-hospitalizations (45 vs. 60) and hospital days (252 vs. 351) at 3 months (P < 0.041).
- Associated with short-term cost savings of $439/member/month and cumulative savings of $2170/member at 1 year (P < 0.037).
Conclusions:
- The Transitional Care Model (TCM) can be effectively translated into a large, real-world health plan.
- Implementation of the TCM leads to improved patient outcomes and higher value healthcare.
- The study supports the scalability and effectiveness of the TCM for managing chronically ill older adults.
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