High-value transitional care: translation of research into practice

J Eval Clin Pract. 2013 Oct;19(5):727-33. doi: 10.1111/j.1365-2753.2011.01659.x. Epub 2011 Mar 16.


Objective: To evaluate the impact of translating into a large US health plan, the Transitional Care Model (TCM), an evidence-based approach to address the needs of chronically ill older adults throughout acute episodes of illness.

Methods: A prospective, quasi-experimental study of 172 at-risk Aetna Medicare Advantage members in the mid-Atlantic region who received the TCM. A baseline and post-intervention (average of 2 months) comparison of enrolees' health status and quality of life was conducted. Member and physician satisfaction were assessed within 1 month post intervention. Health resource utilization and cost outcomes were compared to a matched control group of Aetna members at multiple intervals through 1 year.

Results: Improvements in all health status and quality of life measures were observed post- intervention compared to pre-intervention. Among 155 stringently matched pairs, a significant decrease in number of re-hospitalizations (45 vs. 60, P < 0.041) and total hospital days (252 vs. 351, P < 0.032) were observed at 3 months. Reductions in other utilization outcomes or time points were not statistically significant. The TCM was associated with a short-term decrease of $439 per member per month in total health care costs at 3 months and cumulative per member savings of $2170 at 1 year (P < 0.037).

Conclusions: Findings demonstrate that a rigorously tested model of transitional care for chronically ill older adults can be successfully translated into a real-world organization and achieve higher value.

Keywords: care coordination; chronic disease; evidence translation; evidence-based practice; geriatrics; transitional care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Chronic Disease* / epidemiology
  • Chronic Disease* / psychology
  • Chronic Disease* / therapy
  • Episode of Care
  • Evidence-Based Practice / methods
  • Evidence-Based Practice / standards
  • Health Care Costs
  • Health Planning* / methods
  • Health Planning* / organization & administration
  • Health Services for the Aged / organization & administration*
  • Health Status Disparities
  • Hospitalization / economics
  • Hospitalization / statistics & numerical data
  • Humans
  • Models, Organizational
  • Needs Assessment
  • Quality of Life
  • Translational Medical Research
  • United States