Arnold Ventures Awards $6 Million Grant to Study Replication of Penn Nursing’s Transitional Care Model

Study Will Evaluate the Effectiveness of TCM in Reducing Rehospitalizations and Promote Widespread Use of the Program in a Number of Health Systems

Newswise — PHILADELPHIA (March 4, 2020) – A $6 million grant from Arnold Ventures will support replication and rigorous study of the outcomes of the Transitional Care Model (TCM) in four U.S. health care systems. Designed by a team at the University of Pennsylvania School of Nursing (Penn Nursing), the TCM has been proven in multiple National Institutes of Health (NIH)-funded randomized clinical trials (RCTs) to improve health outcomes, reduce rehospitalizations and decrease total health care costs among the growing population of Medicare beneficiaries.

“To achieve positive outcomes for older adults with complex health and social needs, an advanced practice registered nurse (APRN) collaborates with patients, their family caregivers, and healthcare teams to design and implement individualized plans of care that extend from hospital to home,” explained the project’s lead, Mary Naylor, PhD, RN, FAAN, the Marian S. Ware Professor in Gerontology and the Director of the NewCourtland Center for Transitions and Health. Naylor is the architect of the TCM at Penn Nursing.

The study will evaluate the effects of the TCM in nine hospitals located in five states which are part of Swedish Health Services, Trinity Health, University of California San Francisco (UCSF) Health, and the Veterans Health Administration. Together, these systems will recruit 1,600 Medicare patients to participate in this RCT. Mathematica will conduct an independent evaluation, led by Randall Brown, PhD and Arka Ghosh, PhD.

“TCM has very promising evidence of sizable reductions in rehospitalizations and net healthcare costs among Medicare beneficiaries,” says Erin Crossett, Evidence-Based Policy Manager of Arnold Ventures that awarded the grant. The grant is part of the organization’s Moving the Needle initiative to expand delivery of programs that have been rigorously shown to improve important life outcomes, ensuring significant headway against U.S. social problems. “The successful replication of TCM would provide convincing evidence that TCM could be used in hospitals nationwide to improve patient health and generate major healthcare savings” said Crossett.

When the trial is launched, the Penn Nursing team (led by Naylor) will coordinate the initiative, providing participating sites with the training and support essential to implement the TCM as designed. The overall goal of the study is to determine if the health and economic benefits demonstrated by the TCM in NIH-funded RCTs conducted in Pennsylvania can be replicated both within and across health systems spread throughout the U.S.

“If the TCM’s effects can be reproduced, participating health systems are committed to spread the model, accelerating their ongoing efforts to improve the care and outcomes of the growing population of older adults living with complex needs. Evidence that the TCM is generalizable also will encourage voluntary adoption among other health systems,” says Naylor.

The Penn team also will examine factors that may influence the implementation and, if successful, health systems’ expansion of the TCM. “With a diverse set of hospitals in terms of size, geographic location, patient population, and post-acute and community-based service partners, the RCT findings will provide an actionable path for the Centers for Medicare and Medicaid Services and other payers to reduce healthcare costs among Medicare beneficiaries, while maintaining high quality care,” says Naylor.


MEDIA CONTACTS                              

Ed Federico                                                                                         

Penn Nursing                                       


[email protected]                               


David Hebert

Arnold Ventures


[email protected]


Amy Berridge



[email protected]


Scott Maier                                            

University of California San Francisco   

[email protected]                        


Amy Middleton

IHA (Trinity Health)


[email protected]

About the University of Pennsylvania School of Nursing

The University of Pennsylvania School of Nursing is one of the world’s leading schools of nursing. For the fourth year in a row, it is ranked the #1 nursing school in the world by QS University and is consistently ranked highly in the U.S. News & World Report annual list of best graduate schools. Penn Nursing is currently ranked # 1 in funding from the National Institutes of Health, among other schools of nursing, for the third consecutive year. Penn Nursing prepares nurse scientists and nurse leaders to meet the health needs of a global society through innovation in research, education, and practice. Follow Penn Nursing on: Facebook, Twitter, LinkedIn, & Instagram.  

About Arnold Ventures

Arnold Ventures’ core objective is to maximize opportunity and minimize injustice. We are a philanthropy dedicated to tackling some of the most pressing problems in the United States. Arnold Ventures invests in sustainable change, building it from the ground up based on research, deep thinking and a strong foundation of evidence. We drive public conversation, craft policy and inspire action through education and advocacy. For more information on Arnold Ventures and its healthcare work, visit

About Mathematica

Mathematica applies expertise at the intersection of data, methods, policy, and practice to improve well-being around the world. We collaborate closely with public- and private-sector partners to translate big questions into deep insights that improve programs, refine strategies, and enhance understanding

About IHA (Trinity Health)

Established in 1994 and lead by physicians, IHA is one of the largest multi-specialty medical groups in Southeast Michigan, practicing based on the guiding principle: our family caring for yours. IHA is committed to providing the best care with the best outcomes for every patient and an exceptional work experience for every provider and employee. IHA offers patients from infancy through senior years, access to convenient, quality health care with extended office hours and urgent care services, online patient diagnosis, treatment and appointment access tools. Based in Ann Arbor, IHA employs more than 3,000 staff and providers in more than 100 practices. IHA is a wholly-owned subsidiary of Saint Joseph Mercy Health System and a member of Trinity Health. To learn more about IHA, visit

About Saint Joseph Mercy Health System (Trinity Health)

Saint Joseph Mercy Health System (SJMHS) is a health care organization serving seven counties in southeast Michigan including Livingston, Washtenaw, Wayne, Oakland, Macomb, Jackson, and Lenawee. It includes 548-bed St. Joseph Mercy Ann Arbor, 497-bed St. Joseph Mercy Oakland in Pontiac, 304-bed St. Mary Mercy Livonia, 66-bed St. Joseph Mercy Livingston in Howell, and 133-bed St. Joseph Mercy Chelsea.  Combined, the five hospitals are licensed for 1,548 beds, have five outpatient health centers, six urgent care facilities, more than 25 specialty centers; employ more than 15,300 individuals and have a medical staff of nearly 2,700 physicians.   SJMHS has annual operating revenues of about $2 billion and returns about $115 million to its communities annually through charity care and community benefit programs.

SJMHS is a member of Trinity Health, a leading Catholic health care system based in Livonia, Mich. Trinity Health operates in 22 states, employs about 133,000 colleagues, has annual operating revenues of $17.6 billion and assets of about $24.7 billion. Additionally, the organization returns almost $1.1 billion to its communities annually in the form of charity care and other community benefit programs.

For more information on health services offered at Saint Joseph Mercy Health System, please visit