Mary D. Naylor, PhD, RN, is the Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania, School of Nursing. Since 1989, Dr. Naylor has led an interdisciplinary program of research designed to improve the quality of care, decrease unnecessary hospitalizations and reduce health care costs for vulnerable community-based elders. Dr. Naylor is also the National Program Director for the Robert Wood Johnson Foundation program, Interdisciplinary Nursing Quality Research Initiative (INQRI), which is aimed at generating, disseminating and translating research to understand how nurses contribute to and can improve the quality of patient care. In recognition of her research and leadership, Dr. Naylor has received numerous awards including the first nurse selected as a McCann Scholar (2004) and election to the National Academy of Sciences, Institute of Medicine (2005).

“This model directly responds to the most threatening health care problems facing this nation—the rapidly growing number of chronically ill patients and the disproportionate rate of health care expenditures (e.g., hospitalizations) among these patients. For that reason, TCM serves both a quality of care need and a policy imperative.”

“People with chronic conditions must navigate a care system that is ill equipped to meet their needs. The human and economic toll is devastating. Findings from our team’s work and that of others offer promising solutions to address the care needs of chronically ill people in this country and internationally. We need the political will to change clinical practices and policies in order to implement evidence-based transitional care.”