Original ArticlesAdvancing High Value Transitional Care The Central Role of Nursing and Its LeadershipNaylor, Mary D. PhD, RNAuthor Information NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia. Correspondence: Mary D. Naylor, PHD, RN, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, 418 Curie Blvd, Claire M. Fagin Hall Room 341, Philadelphia, PA 19104 ([email protected]). I am deeply grateful to the patients, family caregivers, advanced practice nurses and other health care professionals, research team members, health system and health plan partners, and sponsors whose commitment to higher-value health care has made this journey possible. The author declares no conflict of interest. Nursing Administration Quarterly: April/June 2012 - Volume 36 - Issue 2 - p 115-126 doi: 10.1097/NAQ.0b013e31824a040b Buy Metrics Abstract Addressing the health care needs of older adults coping with multiple conditions and their family caregivers in a person- and family-centered, safe, effective, efficient, equitable, and timely manner will be a major issue confronting America's health care system for the foreseeable future. This article describes the efforts of a multidisciplinary team to create a path from system fragmentation to integration for this vulnerable population through the design, testing, and translation of the Transitional Care Model (TCM). The TCM is a nurse-led, team-based care delivery system innovation that is designed to increase alignment of the care system with the preferences, needs, and values of high-risk individuals and their family caregivers and achieve higher-quality outcomes while reducing health care costs. A rigorous body of evidence reinforces a tremendous opportunity to address the urgent need for higher-value health care, through widespread implementation of the TCM for chronically ill older adults. Capitalizing on this opportunity will require the investment, commitment, and support of nursing and its leadership. © 2012 Lippincott Williams & Wilkins, Inc.