Partnerships
Translating Research Into Practice
A growing body of science suggests that older adults coping with multiple chronic conditions and complex therapies are particularly vulnerable to breakdowns in care.1 Insufficient communication among providers and across health care agencies, inadequate patient and caregiver education, poor continuity of care, and limited access to services are among the major factors contributing to negative quality and cost outcomes. For example, the "hand-off" from hospital to home of more than one-third of older adults and caregivers has been linked to serious unmet needs and poor satisfaction with care. Rehospitalization rates for these patients are very high, with one-quarter to one-third considered preventable. A recent Institute of Medicine (IOM) report identified care coordination as one of 20 national priorities for action.2 IOMs priorities reflect quality issues affecting a large segment of the U.S. population with the widest gap between evidence-based "best practice" and current care.3
Progress
To bridge the gap between research, evidence-based "best practices" and the real world of health care, the PENN Team established partnerships with a major health insurer (Aetna Corporation), and health care organizations (Kaiser Permanente)to evaluate their implementation of the Transitional Care Model within their organizational context, through the support of The Commonwealth Fund, Jacob & Valeria Langeloth Foundation, The John A. Hartford Foundation, Inc., Gordon & Betty Moore Foundation, California HealthCare Foundation.
With our colleagues at Kaiser Permanente (KP) [Northern California region] alternative nurse staffing models are being examined, across three KP hospital sites the effects of translating and integrating the Transitional Care Model within the KP system in geographically diverse areas using Advanced Practice Nurses (APN) only, Registered Nurses (RN) working in consultation with APNs, or RNs only. This project is designed to substantially improve the coordination of care and outcomes of the growing population of high risk older adults by informing and influencing decision making at the clinical, organizational, health system, and public policy levels regarding the quality and cost benefits associated with translating the Transitional Care Model.
In response to the success of the model demonstration with Aetna Corporation (Mid-Atlantic region), the University of Pennsylvania Health System (UPHS) has adopted and is deploying TCM presently. Independence Blue Cross has signed on as the first insurer to reimburse for program through UPHS.
1Naylor, M.D. (2002). Transitional care of older adults. In P. Archbold, & B. Stewart (Eds.) Annual Review of Nursing Research, (pp. 127-147). New York: Springer.
2Committee on Quality Health Care in America (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine, National Academy of Sciences, Washington DC: National Academy Press.
3Adams, K. & Corrigan, J. (Eds.) and Committee on Identifying Priority Areas for Quality Improvement (2003). Priorities for National Action: Transforming Health Care Quality. Institute of Medicine, National Academy of Sciences, Washington DC: National Academy Press.