A Review of Current Policies and Utilization with Recommendations for Improving Value
Improving Care for Older Adults
Mary Naylor Honored by National Academy of Medicine for Advancing Health Care
Receives 2022 Lienhard Award for Pioneering Work in Transitional Care for Older Adults
Mary Naylor, LDI Senior Fellow and University of Pennsylvania School of Nursing Professor, has received the National Academy of Medicine (NAM) 2022 Gustav O. Lienhard Award for her pioneering work in the field of transitional care for at-risk older adults. The award was presented at the October 16 NAM Annual Meeting in Washington, D.C.
A member of the Academy since 2005, Naylor, PhD, RN, has spent the last two decades at the Nursing School’s NewCourtland Center for Transitions and Health designing, testing, and implementing the Transitional Care Model (TCM) for chronically ill adults and their family caregivers.
According to the Center for Health Care Strategies, Naylor’s TCM system has been implemented in hundreds of health care organizations and communities in 46 states across the U.S.
20 Years of Persistence
“Overcoming barriers to initial implementation of the Transitional Care Model, and more recently the added challenges due to the COVID-19 pandemic, Dr. Naylor’s persistence over the past two decades has enabled older adults to receive the quality and continuity of care they deserve,” said National Academy of Medicine President Victor J. Dzau. “Her pioneering research placed a national spotlight on what is possible when health and social care systems are aligned with people’s goals and changing needs, in order to address social determinants at the point of care. Dr. Naylor’s tireless efforts to establish the field of transitional care for older adults and their caregivers, coupled with her championing of nurses and preparing the next generation for care transitions, make her most deserving of this prestigious award.”
The TCM system hallmarks include:
- Engaging at-risk older adults and caregivers during episodes of acute illness
- Establishing trusting relationships between advanced practice registered nurses (APRNs) and older adults and their caregivers
- Identifying and then advocating for older adults’ goals to drive their plans of care
- Providing continuity of care by the same APRN throughout a patient’s illness experiences
- Coordinating care with multiple clinicians and staff across settings
Findings from three consecutive National Institutes of Health-funded randomized controlled trials led by Naylor consistently demonstrated the effectiveness of the TCM in enhancing the care experiences of at-risk hospitalized older adults as they transitioned to home settings, while improving their functional status and quality of life. These outcomes were achieved by different racial groups and accompanied by significant reductions in avoidable re-hospitalizations and substantial health care savings.
Established in 1986, the Academy’s Lienhard Award recognizes individuals “for outstanding achievement in improving health care services in the United States.” Support for the award is provided by the Robert Wood Johnson Foundation (RWJF).”
Former President and Chairman of Johnson & Johnson, Gustav O. Lienhard was chairman of RWJF from 1971 to 1986 as the Foundation moved to the forefront of American philanthropy in health care. It currently distributes about $500 million annually to various health care programs and research projects.
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