Some researchers develop and test new models of care for certain patient populations. Others focus on applying and testing interventions in real-world settings. A few hearty souls strive to translate successful models into widespread use. Mary Naylor does all three. Over two decades she has designed, tested, implemented, and translated a model of transitional care to improve outcomes for frail elderly patients.
Dr. Naylor’s Transitional Care Model (TCM) is an advanced practice nurse-led, team-based, hospital-to-home care innovation. A decade of rigorous research demonstrated its effectiveness in hospitalized elderly patients, in heart failure patients, in English and Spanish speaking older adults in assisted living facilities and nursing homes, and in cognitively impaired patients in long term care. Multiple studies demonstrated that TCM improved patients’ experience with care, enhanced quality of life, reduced rehospitalizations, and reduced health care costs over the short and longer term.
Subsequent work showed that TCM reduced rehospitalizations in community-based, cognitively impaired older adults. She has integrated transitional care into patient-centered medical homes and into palliative care. The Coalition for Evidence-Based Policy has recognized the TCM as a “top tier” evidence-based approach that, if scaled, could have a positive impact on the health and well-being of chronically ill adults while assuring wiser use of societal resources.
In addition to demonstrating the effectiveness of transitional care, Dr. Naylor has led the translation of her findings into wide adoption. A successful partnership between Aetna and Penn (UPHS) launched TCM into a major health system, where it is now a reimbursable service line within the UPHS home care and hospice division. She has provided technical assistance and educational programs for local adaptations of Transitional Care Model. In a Robert Wood Johnson Foundation-sponsored study of local TCM adaptations, 59% of responding health systems and communities (344/582) reported use of the TCM as a foundation for care redesign. She is site PI for Project ACHIEVE (2014-19), a PCORI initiative to improve transitional care programs and outcomes from a patient and family perspective. She now directs the NewCourtland Center for Transitions and Health, which generates, disseminates and translates research related to nursing's influence on major health transitions—developmental, situational, illness-related or contextual—for chronically ill adults.
Dr. Naylor has also been a leader in building the evidence linking nursing to the quality of care delivered by nurses. With Mark Pauly, Naylor designed and directed the RWJF Interdisciplinary Nursing Quality Research Quality Initiative (INQRI) that tested and validated nurse-sensitive outcomes measures that were adopted by the National Quality Forum.
Dr. Naylor was elected to the National Academy of Medicine (NAM) in 2005; she is a member of NAM’s Leadership Consortium for Value & Science-Driven Health Care and co-chairs the Care Culture and Decision-Making Innovation Collaborative. She also is a member of the ABIM Foundation Board of Trustees, RAND Health Board of Advisors and the Agency for Healthcare Research and Quality (AHRQ) National Advisory Council. In 2016, she completed her six-year term as a member of Medicare’s Payment Advisory (MedPAC) Commission. In 2016, she was honored with AcademyHealth's Distinguished Investigator Award.