A Conversation With Mary D. Naylor, PhD, RN: Managing the Transition From the Hospital

A pioneering advocate for transitional care for older adults and their caregivers sees growing interest in her evidence-based approach

Even though Mary Naylor, PhD, RN, and her team could prove that their approach to caring for elderly patients as they made the transition from hospital to home could improve outcomes and reduce costs, that didn’t mean that the model would be adopted, at least not overnight. The success was years in the making – and their Transitional Care Model is still far from ubiquitous. But today’s environment of change and the advent of accountable care organizations means that the odds are better than ever that more patients will have access to advanced practice nurses who provide continuity of care and coordination of health and social services, says Naylor, the Marian S. Ware Professor in Gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing.

“I am glad we hung in there. We are seeing the care delivery systems align better with people’s needs. Managed health care is creating the conditions and the incentives – both quality and financial – for this kind of approach to care to scale more quickly than it has.”

Her team’s patience and meticulous attention to collecting data on effectiveness can also be an example for other proposed innovations in the health care system, she says.

Naylor, a fellow of the American Academy of Nursing, is a member of the Medicare Payment Advisory Commission – MedPAC. She is the national program director for the Robert Wood Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative, a member of the Rand Health advisory board and of the National Quality Forum board of directors, and the founding chairwoman of the Long Term Quality Alliance. She also serves on the Institute of Medicine’s health care services board. She spoke recently with Managed Care Editor John Marcille.

Managed Care: How did the Transitional Care Model come about?

Mary D. Naylor, PhD, RN: When I came to the University of Pennsylvania School of Nursing, I had just completed a W. K. Kellogg leadership fellowship with the Senate Committee on Aging. When I arrived at Penn, I connected with Dorothy Brooten, the Transitional Care Model’s (TCMs) original architect. Her team had tested this care delivery innovation with very-low-birth-weight infants. Study results demonstrated the capacity of the TCM to reduce length of stay and costs, if an infant’s care was coordinated by advanced practice nurses who were working collaboratively with the family, physicians, and other health care team members. Our team recognized a common vulnerability with older adults: It’s not just progression of health problems that contributes to poor outcomes; it is often social issues. It might be economic issues, such as inability to pay the copays for medications or challenges with health literacy. A new mutidisciplinary team agreed that these common-ground issues were sufficient to apply the model to older adults.

MC: You spent years proving that your version of the TCM could work.

Naylor: Many National Institutes of Health multi-site randomized clinical trials showed that we can get to better patient outcomes, better experiences with care, and reduced costs with this model. We had papers published in top-tiered journals, with substantial publicity, as each trial was reported. But then we realized that nobody was applying what we had uncovered. Over time, we realized there was little alignment of this model with quality and payment incentives. Hospital staff were not conditioned to speak – as they are now – with home care and skilled-nursing staff or family caregivers. Ultimately, we realized we didn’t have a care culture focused on older adults and their complex needs.

MC: Things are different today?

Naylor: There are many promising signs. There’s no question that the importance of transitional care is now understood. CMS recently introduced transitional care payment codes. This small advance does not support the TCM, but is evidence of the need for follow-up care of hospitalized Medicare beneficiaries. CMS is testing many transitional care delivery and payment approaches that, if proven successful, can be quickly scaled. Leaders of evolving accountable care organizations understand that they have to optimize care that clearly aligns with the needs of people, in order to get these results. They are very interested in the TCM.

MC: What was the key in moving the Transitional Care Model from clinical trials to practice?

Naylor: We partnered with Aetna to determine whether we could replicate what we learned in clinical trials in the real world. We were able to demonstrate improvements in all assessed patient outcomes as well as in the physicians’ experience in managing high-risk, chronically ill older adults,reductions in rehospitalizations and costs. The University of Pennsylvania Health System (UPHS) and many others have adopted or adapted the model. Independence Blue Cross and Aetna are reimbursing the UPHS to deliver this evidence-based approach to care for their members. Managed care leaders understand the capacity of this care approach to improve population health and achieve longer term value

MC: What product are you selling?

Naylor: The product depends on the site. Our team initially focused on the movement of older adults from hospitals to home. We have extended our efforts to include transitions through skilled-nursing facilities to home. We have tested the model in patient-centered medical homes, integrating the model to focus on high-risk, chronically ill older adults and prevent initial hospitalizations.

MC: How does the model work?

Naylor: We use evidence-based criteria to identify who will benefit from transitional care. So if Mr. Smith is screened as at-risk for poor outcomes and agrees to the service, a master’s-prepared advanced practice nurse, who has achieved certain competencies related to transitional care, is deployed. The transitional nurse works with staff to promote positive hospital outcomes and prevent common problems such as functional decline, falls, and infection. That same nurse visits Mr. Smith in his home within 24 hours and accompanies him to the first follow-up visit with his community-based provider to make sure there’s optimal communication between the hospital and the community-based clinician. If, during a home visit, for example, the nurse notices that Mr. Smith is declining, the nurse and physician can collaborate to avoid preventable emergency department visits or hospitalizations.

Older adults really value care continuity. The same nurse is involved in the entire episode of care, from the initial hospital admission through an average of two months post transition.

MC: The advanced practice nurse is providing the home care?

Naylor: The program substitutes for traditional home care by nurses. Older adults really value care continuity. The same nurse is involved in the entire episode of care, from the initial hospital admission through an average of two months post transition. Throughout this period, the nurse is helping Mr. Smith figure out how to manage or prevent all of the challenges that resulted in multiple emergency room visits or hospitalizations in the past. The care plan is driven by Mr. Smith –his goals, preferences, and needs.

MC: Everything depends on the nurses?

Naylor: It depends on the nurses’ capacity to engage Mr. Smith, his family caregivers, physicians and other health team members. Mr. Smith is not someone who’s hospitalized for a minor health problem for the first time. He is typically coping with multiple chronic illnesses or a serious, advanced illness. The transitional care nurses are very sophisticated in their ability to assess the priority problems that, if unaddressed, will probably result in poor outcomes for Mr. Smith, and they are very system-savvy. They work to assure all members of the health team agree on a plan of care that is aligned with Mr. Smith’s goals and preferences and needs. That means that they have a capacity to communicate and collaborate and advocate on behalf of Mr. Smith. The nurses emphasizes palliative care and, when appropriate and consistent with Mr. Smith’s goals, help in the transition to hospice.

MC: This all seems desirable from several points of view.

Naylor: We have been at this for many years, and some days, we wonder why the move to this approach is so challenging, especially since our team seeks this approach for our loved ones and ourselves. We are using multiple strategies to scale the TCM, including a commercial venture through Penn’s technology transfer department.

MC: Can your business case inspire insurers to get on board?

Naylor: The business case is exceedingly important. From the outset, we have examined the TCM from the perspectives of both benefits and costs. Are people able to manage their symptoms better? Do they feel that someone has been in charge of their care? Do they have a sense that their quality of life is better? These are things that matter to people. We also looked at what it costs in our system to achieve these benefits; what is the long-term impact? One clinical trial demonstrated significant reductions in rehospitalizations among heart failure patients through one year following enrollment. We also have compared the effectiveness of the TCM to other evidence-based approaches. Not surprisingly, the cost findings have received the most attention. We view 30-day rehospitalization rates as a marker but certainly not the end point. The real definition of success is interrupting the progression of chronic illnesses and helping people receive the services that matter to them. That is, our efforts emphasize long-term value.

MC: Are certain organizations more interested in that than others?

Naylor: Accountable care organizations are certainly interested in making the TCM a part of their care system. We are also working with patient-centered medical homes. These community-based practices place a premium on care coordination, but often they don’t have the capacity to do the things that we can do in partnership with them. So advanced practice nurses can target the high-risk patients, go into the home, and follow up on the priority issues. They do this in strong collaboration with the primary care physicians.

MC: How widespread is the use of the TCM?

Naylor: The Robert Wood Johnson Foundation is funding a national study that will help us to know how sites have adopted or adapted the TCM. We certainly know about some health systems and communities, because we are working with them. But we also know that the provisions in the Affordable Care Act regarding community-based care transition programs, hospital readmission reduction programs, and shared savings programs, all highlight the importance of evidence-based transitional care – not necessarily our approach, but evidence-based transitional care models. We have developed a training program for nurses and other health care team members across the country to help them get oriented to the TCM. We provide consultation services. For example, we worked with Baylor Health Care System at its very early stages, and I understand that multiple hospitals within this system are now implementing the model. We are working on a project at Cedars-Sinai Medical Center in Los Angeles, where they are attempting to connect the great work that they have been doing with frail elders with better follow-up care in the community. A community in northern New Jersey is implementing the Transitional Care Model to target a growing population of older adults living in rural communities to enable them to stay in their homes.

MC: Are you also studying how insurers are paying for this kind of care?

Naylor: As noted earlier, the UPHS the has established the TCM as a service line within its home care and hospice division and local insurers are reimbursing for this service. We are examining the effects of innovative payment methods such as case rates and risk bearing contracts in partnership with these insurers.

MC: Would a large organization bring that in-house?

Naylor: This is care delivery, and so it’s a partnership between the managed care organization and the care deliverers. Most insurers rely on case management, typically deployed through telephonic services. Our efforts are to partner with insurers, to extend care to those who require more than telephonic support.

Roles, at least for some clinicians, cannot be bounded by hospital doors. They need to extend across settings and teams.

MC: What would be the typical caseload for a nurse in this role?

Naylor: Reported studies suggest that one nurse can care for 20 high risk patients, assuming responsibility for daily hospital visits, building the transitional care plan, delivering and implementing that plan in the patient’s home, and delivering and coordinating care for an average of two months following a hospital discharge.

MC: It sounds like a lot of work.

Naylor: In health care, we have often positioned people to work well in one setting, such as in an emergency department or intensive care unit. But in our model we have nurses working with all team members that are involved in Mr. Smith’s care while hospitalized. These nurses are responsible for the delivery of care in post-acute care facilities and the patient’s home following transition from the hospital. Care in the home often requires a very different skill set, where nurses are figuring out how to help Mr. Smith access community services such as Meals on Wheels and transportation, to make sure that Mr. Smith is not going back to the emergency room because he is not well nourished or doesn’t have transportation to follow-up visits. We have also been trying to figure out how to prepare the existing work force to focus much more on chronic illness and population health – vitally important issues for accountable systems. That means that roles, at least for some clinicians cannot be bounded by hospital doors.

MC: What are some of the things that make your nurses more flexible?

Naylor: These nurses are credentialed in primary care practices and in hospitals, in the sites that match Mr. Smith’s experience over an episode of care. The nurses possess competencies that enable them to address acute and post-acute needs.

MC: You are optimistic?

Naylor: Our conversations about the importance of patient engagement nationally, and the conversations about payment for care coordination broadly, are all signs of movement from a fee-for-service system to a payment model that aligns much better with this approach to care. Consumers who have lived with the experience or witnessed what has happened to relatives and friends are beginning to become a strong voice for change. They expect and deserve better alignment with their care needs – better care coordination. We are not going to turn the current payment system upside down tomorrow, but incrementally can change the system to support evidence-based services such as the TCM, then we will be on the path to better health outcomes for the growing population of chronically and seriously ill people and much wiser use of our finite resources.

MC: You have given policymakers a lot of evidence to get behind this model. That’s not always the case when legislators consider innovations.

Naylor: The TCM has been recognized by the Coalition for Evidence-Based Policy as a top-tier evidence-based approach that if scaled could result in major savings and do something very good for the care of people. From the outset, Mark V. Pauly, PhD, has been the lead health care economist on our team. We have always looked at this as trying to figure out how evidence creates a foundation for change. It is in the best interest of our society to mount change based on what we know works and doesn’t work. Decisions based on how we are going to change care design should be grounded in what we know works for whom, for how long, and at what cost.

MC: What are you doing to promote evidence-based change broadly?

Naylor: In addition to my role on a number of key policy-making groups, Mark and I head a program for the Robert Wood Johnson Foundation that is designed to try to show health system leaders and policymakers, through rigorous evidence, how nurses contribute to health care value.

MC: You are preparing a road map for others who want to bring empirically tested research into their organizations. Is that related?

Naylor: When multiple clinical trials demonstrated little impact on practice, our team decided it was up to us to move evidence into real-world systems. We built high risk screening tools. We created a Web-based system to prepare nurses and other team members to implement the TCM. We built and tested performance improvement programs. While we always have had benchmarks to measure progression, these have become more sophisticated over time. Every time we work with a system, we assess facilitators and barriers to change and, as a result, we anticipate challenges and get better.

MC: Thank you.

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