Penn professor pushes a new approach to elder care

Mary Naylor, a professor of gerontology at Penn's School of Nursing, helped devise a patient-care model that coordinates treatment before and after hospital visits.
Mary Naylor, a professor of gerontology at Penn's School of Nursing, helped devise a patient-care model that coordinates treatment before and after hospital visits. (CHARLES FOX / Staff Photographer)
Posted: September 26, 2011

Since 1989, Mary Naylor, a professor of gerontology at the University of Pennsylvania School of Nursing, has advocated for a different way of caring for an especially costly group of patients: older people with chronic illnesses who cycle in and out of hospitals. The transitional-care model she helped devise uses master's-level nurses to coordinate care before and after patients leave the hospital to prevent them from getting back into trouble. One study found Naylor's approach saved Medicare $3,000 per patient over six months and $5,000 over a year.

Penn has adopted the program, and Aetna and Independence Blue Cross have paid for it here. The idea has been slow to take off nationally, though.

Naylor says the new health law, with its emphasis on greater care coordination and quality is spurring a big uptick in interest.

"We cannot continue the system as it is," said Naylor, who spoke to Inquirer staff writer Stacey Burling.

A petite woman who says she is "younger than you think" - she graduated from Villanova in 1971 so you can do the math - Naylor has tried skydiving and zip-lining in her spare time. She is a member of the Institute of Medicine, on the boards of the National Quality Forum and the Long Term Quality Alliance, and on the Medicare Payment Advisory Commission.


Question: Why did you become a nurse?

Mary Naylor: I volunteered during high school at Bryn Mawr Hospital and became very interested in doing something that would have contact with people. I met [nurses] when I was volunteering and I kept saying, 'Wow, I'd really like to be doing what they're doing and having the impact that they're having.' "

Q: Your claim to fame is the transitional-care model. How and when did you develop that?

Naylor: [On a fellowship] I became exposed to policies that affect care of older adults very directly. One was the prospective payment system for hospitals that resulted in shorter lengths of stay, people being discharged quicker and sicker. That became really a calling to arms for me, this notion that some people were being very negatively affected. What can we do about it?

Q: What was your goal?

Naylor: Our question has always been: Can we get to better quality for high-risk older adults and their families at reduced cost? And that's what the transitional-care model has consistently demonstrated.

Q: Do you think we're asking too much of families now?

Naylor: I do. There's this huge movement toward promoting self-care and I think that that's really important, but I also think that people come to a point in their life where they need care. They need support. I totally don't think we've made the investment in the individual patients and certainly in their family caregivers . . . that would really position them with the knowledge and skills and resources that they need in order to feel good.

Q: How does your model fit into the Affordable Care Act?

Naylor: The Affordable Care Act offers several provisions that I think could ignite implementation of this model on a wide scale. Certainly the Center for Medicare and Medicaid Innovation - $10 billion allocated to scale evidence-based approaches that will get to higher value for the Medicare beneficiary - is a huge opportunity. . . . The Accountable Care Organization, an effort to take on numbers of high-risk Medicare beneficiaries and to get to better care, better outcomes for them, I think represents an important opportunity. Already the Partnership for Patients announced that $500 million will be going directly to hospitals and their community-based partners to help them figure out how to work better together to improve care transitions.

And finally, we have payment innovations like the bundled payments in which you'll get payment for hospital and post-acute care as an episode, and that will really encourage hospitals and post-acute providers and community organizations to collaborate on addressing people's needs.

Q: Has the transitional-care model been widely adopted?

Naylor: No. [She laughs uproariously for a few seconds.] But we're on a path, on a path. This is all in the last couple of months. We are working, I cannot tell you with how many systems, to try to position them.

Q: Is it the Affordable Care Act that's suddenly gotten everybody's attention?

Naylor: It is absolutely the sun, moon, and stars aligning, recognition of growing populations of people entering the Medicare program, this real search for really strong evidence-based solutions that get to better care at the same time they reduce cost, the real concern about the growth of the Medicare program . . . and all of that aligning with incentives in the Affordable Care Act.

Contact staff writer Stacey Burling at 215-854-4944 or


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