Transitional Care Legislation

I am proud to write to you about the stellar testimony before the U.S. Senate Finance Committee by one of our faculty which has led to Congressional bills that are likely to enhance quality of care and decrease disparities. As many of you know, Mary D Naylor, PhD, FAAN, RN, the Marian S. Ware Professor in Gerontology and director of NewCourtland Center for Transitions and Health, has been in the forefront of research producing the evidence for a care model to assist and manage the multiplicity of health problems of frail elders as they move from hospital to home. This transitional care model has the potential of enhancing the quality of life of these patients and their families as well as decreasing cost.

Currently, Dr. Naylor’s model has the potential, with your help, to become law. Findings from her and her team’s research form the basis of the “Medicare Transitional Care Act (H.R.2773) sponsored by Earl Blumenauer (D-OR) and Charles Boustany (R-LA) which was introduced this week in the U.S. House of Representatives. This important legislation is designed to eliminate the thousands of preventable hospital readmissions that occur each year by providing high quality transitional care to high-risk Medicare beneficiaries throughout episodes of acute illness.

Since 1989, Dr. Naylor has led an interdisciplinary program of research designed to improve outcomes and reduce costs of care for vulnerable community-based elders. To date, Dr. Naylor and her research team have completed three National Institute of Nursing Research (NINR)-funded randomized clinical trials focusing on discharge planning and home follow up of high-risk elders by advanced practice nurses. Dr. Naylor and her team of researchers partnered with Aetna Corporation and Kaiser Permanente Health Plan to apply the model in everyday practice. Throughout testing, the model has proven to provide improved quality of care at lower cost by reducing the number of hospital readmissions. One study recently published in the New England Journal of Medicine found that one-third of Medicare beneficiaries are rehospitalized within 90 days leading to billions of dollars of Medicare payments on unplanned hospital readmission. In short, nurse-conducted research is poised to make an impact on the nation’s healthcare and budget by becoming a Medicare benefit.