Mary Naylor, 2015-16 UCSF Presidential Chair, to Discuss Leadership in Transitional Care

Mary Naylor, UC San Francisco’s Presidential Chair for 2015-16, will be visiting the campus in October to discuss her goals of catalyzing interdisciplinary research, education and practice on transitions in health and health care.

The Presidential Chair award aims to enhance quality in existing academic programs or encourage new or interdisciplinary program development, and UCSF allocates funding to support a distinguished visiting professor for up to one year.

Naylor, PhD, RN, FAAN – a professor of gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing – has led the design of the Transitional Care Model (TCM), which consists of evidence-based guidelines that address common breakdowns in care when older adults with multiple chronic conditions and complex therapies transition from acute care to the home or other care setting.

UCSF School of Nursing’s Science of Caring spoke with Naylor ahead of her Oct. 29 lecture. Below is an edited version, or read the full Q&A on the Science of Caring website.

Q: How has the Affordable Care Act (ACA) and health care reform generally changed the country’s approach to transitional care for chronically ill older adults?

The ACA offered a glide path for transitional care. Our research team and others were very engaged in helping [congressional] staff understand the body of evidence related to transitional care and how we should use this major change in health policy to advance the care of at-risk chronically ill people and families throughout common episodes of acute illness.

Our collective efforts contributed to multiple provisions of the ACA focused on improving care transitions, including the CMS (Centers for Medicare and Medicaid Services) Innovation Center allocating $500 million to foster community-based care transition programs.

This specific initiative is explicitly designed to highlight the importance of establishing partnerships between hospitals and community partners to meet the health needs of diverse chronically ill patient populations.

Q: What does it mean to connect hospitals and community partners?

I can best explain this by offering an example. A few weeks ago I visited a health system that is implementing the Transitional Care Model (TCM). The health system, located in an impoverished community, uses advanced practice (AP) nurses supported by other team members to deliver transitional care services from hospitals to patients’ homes.

While demonstrating some improvements in outcomes, the system realized they were not achieving all that was possible, primarily because the people they were serving were unable to meet basic needs such as food, transportation or copayments for medications once they returned home.

The system collaborated with a local food bank to incorporate a meal service that was adapted to the needs of people living with heart failure, diabetes or other common conditions. Now, upon discharge, each patient receives five days of nutritious meals.

It’s those kinds of partnerships we are trying to foster.

Q: How do we move from encouraging pockets of innovation like this to seeing systemwide change?

On the one hand, the message is to take advantage of innovation opportunities to redesign the care system, [but] with growing evidence that we can achieve better outcomes and reduce costs, disincentives also were included in the ACA to prevent avoidable rehospitalizations for common health problems such as pneumonia. Together, this combination has stimulated massive changes, including embracing evidence-based transitional care as a central component of health system transformation.

Q: There are a lot of definitions of high-value care out there. How do you define it?

Secretary [of Health and Human Services Sylvia] Burwell recently announced a plan to move Medicare’s payment system from one that rewards volume to one that promotes value. The most immediate challenge is to gain consensus on the meaning of value. I believe we need to start with what matters most to people. We need to pay increased attention to people’s needs and preferences, as well as their experiences with care. We need to pay increased attention to people’s needs and preferences, as well as their experiences with care. A distinguishing feature of our team’s approach has been to identify patients’ and family caregivers’ health goals and to craft a plan of care designed to achieve these goals. Reducing unnecessary, costly and sometimes harmful use of health services such as hospitalizations, while important, is only part of the challenge. We need to focus on promoting longer-term gains in health and quality of life and do so by engaging the people our health system supports as key partners in defining these measures. When aligned with people’s goals, we also need to support decisions that allow death with dignity. That’s what I mean by high-value care.

Q: How do you intend to bring what you’ve learned to UCSF?

For the past two years, UCSF leaders and faculty have undertaken considerable planning to transform the UCSF health system, taking a full population health perspective. This means the organization must undertake advances in the organization and delivery of health services that involve the full continuum of care with seamless transitions between each level. I will bring our team’s experience to this process, serving as a catalyst to support activities across disciplines and schools around transitions in care, and provide expertise as the UCSF health system designs and implements transitional care services for diverse populations.

For more campus news and resources, visit Pulse of UCSF.

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