Transitional Care Model

Citation: Naylor, M., Hirschman, K., Hanlon, A., Bowles, K., Bradway, C., McCauley, K., & Pauly, M. (2014). Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults. Journal of Comparative Effectiveness Research, 3(3), 245–257.

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The goal of this study was to compare post-acute care costs of three care management interventions.

Materials & Methods 

A total of 202 hospitalized older adults with cognitive impairment received either Augmented Standard Care, Resource Nurse Care or the Transitional Care Model. The Lin method was used to estimate costs at 30 and 180 days post-index hospital discharge.


The Transitional Care Model had significantly lower costs than the Augmented Standard Care group at both 30 (p < 0.001) and 180 days (p = 0.03) and significantly lower costs than Resource Nurse Care at 30 days (p = 0.02).


These findings suggest that the Transitional Care Model can reduce both the amount of other post-acute care and the total cost of care compared with alternative services for cognitively impaired older adults.