Mary Naylor RN PhD FAAN
NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania
Mary Naylor is a pioneer in the design, evaluation, and spread of health care innovations that have significantly improved the outcomes of chronically ill older adults and their family caregivers, while reducing health care costs. In collaboration with a multidisciplinary team of clinical scholars and health services researchers, her work has resulted in the Transitional Care Model, a cost-effective advanced practice nurse-led model to improve the transitions of older adults who are navigating complex and often fragmented systems of care.
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 but also has improved older adults’ functional status and quality of life. Dr. Naylor has demonstrated how knowledge generated from her research can be used to address the broader challenges associated with chronic illness, the endemic problem of this century.