The Transitional Care Model

Updated: Jan 25, 2018
Evidence Rating:
Top Tier


  • Program:

    A nurse-led hospital discharge and home follow-up program for chronically ill older adults.

  • Evaluation Methods:

    Two well-conducted randomized controlled trials (RCTs).

  • Key Findings:

    30-50% reduction in rehospitalizations, and net savings in health care expenditures of approximately $4,500 per patient, within 5-12 months after patient discharge.

The Transitional Care Model is designed to prevent health complications and rehospitalizations of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up, coordinated by a master’s-level “Transitional Care Nurse” who is trained in the care of people with chronic conditions. At the time of hospitalization, the Nurse: (i) conducts a comprehensive assessment of the patient’s health status, health behaviors, level of social support, and goals; (ii) develops an individualized plan of care consistent with evidence-based guidelines, in collaboration with the patient and her doctors; and (iii) conducts daily patient visits, focused on optimizing patient health at discharge.

Following discharge, the Nurse conducts periodic home visits and/or scheduled phone contacts with the patient based on a standard protocol. In Study 1 (as described in the full evidence summary, available below), the post-discharge program lasted three months, and included an average of 12 home visits, with no scheduled phone contacts. In Study 2 (as described in the full evidence summary, available below), it lasted approximately one month, and included an average of 4.5 home visits and weekly Nurse-initiated phone contacts with patients or family caregivers. In both cases, the Nurse was also available to patients via telephone seven days per week.

Two main focuses of the Nurse home visits and phone contacts are: (i) identifying changes in the patient’s health and (ii) managing and/or preventing health problems, including making any adjustments in therapy in collaboration with the patient’s physicians. The Nurse also accompanies the patient to her first physician visit following hospital discharge to ensure effective communication.

Each Nurse handles a caseload of 18-20 patients. The Transitional Care Model replaces the hospital’s usual discharge-planning and post-discharge activities. Its cost ranges from $519 per patient (in Study 2) to $1,160 per patient (in Study 1), in 2017 dollars.1

Click here to go to the program’s website.

To see our full evidence summary:
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1 This cost estimate includes compensation for the Nurse after patient discharge but not before, since the Nurse’s pre-discharge activities substitute for the hospital’s standard discharge planning. The estimate also does not include the cost of pharmaceuticals, assistive devices, other supplies, or the Nurses’ one-month training in the Model. This same cost formula was used in estimating the net savings from the Model, shown in the full evidence summary.

Study 1 – (Six Philadelphia Hospitals, published 2004):

Naylor, Mary D., Dorothy A. Brooten, Roberta L. Campbell, Greg Maislin, Kathleen M. McCauley, and J. Sanford Schwartz. “Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial.” Journal of American Geriatric Society, 2004, vol. 52, no. 7, pp. 675-684.

Study 2 – (Two Philadelphia Hospitals, published 1999):

Naylor, Mary D., Dorothy Brooten, Roberta Campbell, Barbara S. Jacobsen, Mathy D. Mezey, Mark V. Pauly, and J. Sanford Schwartz. “Comprehensive Discharge Planning and Home Follow-up of Hospitalized Elders: A Randomized Clinical Trial.” JAMA, 1999, vol. 281, no. 7, pp.613-620.

Naylor, Mary D. and Kathleen McCauley. “The Effects of a Discharge Planning and Home Follow-Up Intervention on Elders Hospitalized with Common Medical and Surgical Cardiac Conditions.” The Journal of Cardiovascular Nursing, 1999, vol. 14, no. 1, pp. 44-54.

Other References:

Naylor, Mary D., Karen Hirschman, Alexandra Hanlon, Kathryn Bowles, Christine Bradway, Kathleen McCauley, and Mark Pauly. “Comparison of Evidence-Based Interventions on Outcomes of Hospitalized, Cognitively Impaired Older Adults.” Journal of Comparative Effectiveness Research, 2014, vol. 3, no. 3, pp. 245-257.

Jencks, Stephen, Mark Williams, and Eric Coleman. “Rehospitalization Among Patients in Medicare Fee-For-Service Program.” New England Journal of Medicine, 2009, vol. 360, no. 14, pp. 1418–1428.

Levit K., L. Wier, E. Stranges, K. Ryan, A. Elixhauser. HCUP Facts and Figures: Statistics on Hospital-based Care in the United States, 2007. Rockville, MD: Agency for Healthcare Research and Quality, 2009, pp. 23-24.

Naylor, Mary D., P. Feldman, S. Keating, M.J. Koren, E.T. Kurtzman, M. Maccoy, and R. Krakauer. “Translating Research Into Practice: Transitional Care for Older Adults.” Journal of Evaluation in Clinical Practice, 2009, vol. 15, pp. 1164-1170.

Naylor, Mary D., Dorothy Brooten, Robert Jones, Risa Lavizzo-Mourey, Mathy Mezey, and Mark Pauly. “Comprehensive Discharge Planning for the Hospitalized Elderly: A Randomized Clinical Trial.” Annals of Internal Medicine, 1994, vol. 120, pp. 999-1006.

Naylor, Mary D. “Comprehensive Discharge Planning for Hospitalized Elderly: A Pilot Study.” Nursing Research, 1990, vol. 39, no. 3, pp. 156-161.