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As a result of these findings, a major health insurer has launched a $1 million pilot program to test Dr. Naylor's research in practice.

Participating APNs were given specialized training that emphasized application of educational and behavioral strategies in the home to address patients' and caregivers' unique learning needs. "The goal was to provide these chronically ill patients and their families with the knowledge and management skills necessary to prevent poor outcomes and avoid the need for acute care," said Dr. Naylor. "Working with a major insurer means the nation's elders will immediately reap the benefits of our research, she added.

A randomized sample of 239 patients 65 years or older with a diagnosis of heart failure were assigned to either the group receiving transitional care or a control group that received routine care. Patients in the transitional care group were visited by advanced practice nurses within 24 hours of hospital admission and, upon discharge, the nurses conducted home visits within 24 hours of discharge and were available by telephone. Patients were followed for one year after hospital discharge.

"To date, transitional care programs such as this have typically not been adopted because of lack of Medicare reimbursement, the system's focus on acute versus chronic care, and the organization of care into distinct silos such as hospitals or home care without a safety net to connect them," said Dr. Naylor. The Penn researchers report that a major health insurer will begin to implement the Penn team's model of care in New Jersey, Delaware and Pennsylvania this summer. Older adults at high risk for poor outcomes will participate in the test marketing to verif
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Contact: Lanny Newman
newmanl@mail.nih.gov
301-496-0209
NIH/National Institutes of Health
13-May-2004