The American Geriatrics Society - News - Coordinated Transitional Care Can Significantly Lower Rehospitalization Rates, and Medicare Expenditures, for Seriously Ill Hospitalized Older Adults, Award-Winning Researcher Reports During American Geriatrics Society's Annual Scientific Meeting

FOR IMMEDIATE RELEASE
May 1, 2009

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Erin Weller
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Coordinated Transitional Care Can Significantly Lower Rehospitalization Rates, and Medicare Expenditures, for Seriously Ill Hospitalized Older Adults, Award-Winning Researcher Reports During American Geriatrics Society's Annual Scientific Meeting

Chicago, IL - Providing hospitalized older adults who have complex health problems with coordinated, comprehensive, multidisciplinary transitional care - care that helps them successfully make the transition from hospital to home - can improve outcomes, lower rates of rehospitalization, and cut Medicare costs by thousands of dollars per patient, Mary Naylor, PhD, RN, professor of gerontology and director of the NewCourtland Center for Transitions and Health at the University Of Pennsylvania School Of Nursing, told more than 2,500 geriatrics healthcare professionals here at the American Geriatrics Society's Annual Scientific Meeting yesterday.

During the meeting, which runs through Saturday, the AGS presented Dr. Naylor with its annual Henderson State-of-the Art Award. The award goes to an individual whose research advances understanding of and responses to problems inherent in caring for older adults. The recipient of the award delivers the annual Henderson State-of-the-Art Lecture during the meeting.

Hospitalized older adults with complex health problems often leave the hospital uncertain of what to do next and in need of help, explained Dr. Naylor, whose lecture focused on her groundbreaking research concerning transitional care. As a result, hospital readmission rates among this group are very high. In 2007, the Medicare Payment Advisory Commission (MedPAC) estimated that readmissions of these patients accounted for $15 billion in spending, with 25% of these older adults rehospitalized within 30 days of discharge.

"With complex patients, the rate is even higher… the case for transitional care is very strong," said Dr. Naylor, the leader of a multidisciplinary research program that has pioneered a highly successful care model for these patients, the Transitional Care Model (TCM).

At the heart of the TCM approach is a Transitional Care Nurse (TCN), a nurse with a master's degree and training in implementing the model. The nurse follows the patient from the hospital to the home, working with him or her and his or her family and healthcare providers to prevent declines and rehospitalization. The nurse meets with the patient and family within 48 hours of admission to the hospital and helps them identify their goals for care. He or she also collaborates with the patients' other healthcare providers, working with them to develop a care management plan that meets the patient's needs and goals but isn't too complex for the patient and his or her family to manage. The nurse helps the patient and family understand and follow the plan and recognize and address health problems when they first occur, and keeps his or her other healthcare providers in the loop. The nurse provides these services until the patient is no longer at high risk of rehospitalization, typically for about two months.

To date, Dr. Naylor and her research team have completed three National Institute of Nursing-funded, randomized clinical trials testing and refining the Transitional Care Model. The studies have found that the model can reduce rehospitalization rates more than 20% and lower Medicare costs roughly $5,000 per patient over the course of a year. Aetna, which saw patient outcomes and physician satisfaction improve and costs decline when it tested the model, has identified it as having "high value" and is pursuing it further. Kaiser Permanente Health Plan is also integrating the model into its practices. And the University of Pennsylvania Health System has adopted TCM as a service. Dr. Naylor's team is now testing the approach among hospitalized cognitively impaired older adults.

ABOUT THE AGS

Founded in 1942, the American Geriatrics Society (www.americangeriatrics.org) is a nationwide, not-for-profit association of geriatrics health care professionals dedicated to improving the health, independence, and quality of life of all older people. The Society supports this mission through activities in clinical practice, professional and public education, research, and public policy. With an active membership of over 6,500 health care professionals, the Society has become a pivotal force in shaping attitudes, policies, and practices in geriatric medicine.