Mary D. Naylor, Ph.D., RN, FAAN, the Marian S. Ware Professor in Gerontology, and Director of NewCourtland Center for Transitions and Health in the Department of Biobehavioral Health Sciences at the University of Pennsylvania School of Nursing is the recipient of the 2016 AcademyHealth Distinguished Investigator Award. It honors individuals who have made a significant and long-lasting contribution to the field of health services research, and are leaders and role models in the field.
Naylor is the architect of the Transitional Care Model (TCM), designed to positively impact the care and outcomes of chronically ill older adults who are navigating fragmented systems of care. In collaboration with a multidisciplinary team of clinical scholars and health services researchers, she has tested the TCM and translated the evidence generated within health systems and communities throughout the US and across the globe.
Initially, her team's efforts were focused on the transitions of older adults from hospitals to home. More recently, they have extended their work to prevent avoidable hospitalizations among older adults living in their communities. This evidence-based solution has not only demonstrated better care while reducing health care costs but, importantly also has improved older adults' functional status and quality of life. Additionally, her team expanded the focus of the care model to hospitalized older adults whose care is complicated by cognitive impairment. Unlike earlier randomized clinical trials, this National Institute on Aging (NIA) funded clinical trial compared the effectiveness of the TCM to other evidence-based approaches and resulted in improved patient and health resource outcomes compared to other proven strategies. Naylor and her team also have tested the integration of the TCM within primary care settings. In collaboration with leaders at multiple patient-centered medical homes (PCMHs), a nurse-physician team approach to addressing the needs and goals of high risk community-based older adults was designed and found to improve outcomes relative to the PCMH only.
To accelerate the movement of evidence from her team's work into practice and with the support of many foundations, Naylor has partnered with leaders of health systems, payers and other stakeholders. A 2015 study funded by the Robert Wood Johnson Foundation (RWJF) revealed that approximately 60 percent of responding health systems have adopted or adapted the TCM in the US. Another RWJF study is supporting a partnership with system engineers at the Stevens Institute of Technology to develop a simulation model that will accelerate decision making regarding adoption of the TCM. The Coalition for Evidence-Based Policy (now a part of the Laura and John Arnold Foundation) has recognized the TCM as a "top-tiered" evidence-based approach that, if scaled, could have a positive impact on the health and well-being of chronically ill older adults, while assuring wiser use of societal resources.
Naylor was nominated by Linda H. Aiken, PhD, RN, FAAN, the Claire M. Fagin Leadership Professor in Nursing, Professor of Sociology, and Director of the Center for Health Outcomes and Policy Research, and the first nurse to be awarded this honor. "Dr. Naylor's multiple contributions to health services research and its impact on health care delivery place her among the most successful health services researchers and an extraordinary role model for the field," said Aiken.
Editor's Note: For a high-resolution image of Dr. Naylor, please contact Ed Federico.
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