Medical professional profile

A Legacy Lives On: Mary D. Naylor

Mary D. Naylor, RN, PhD, FAAN, is Marian S. Ware Professor in Gerontology, University of Pennsylvania School of Nursing, and director, NewCourtland Center for Transitions and Health

According to Mary Naylor, Florence Nightingale would have no trouble recognizing today’s nurses.

“They have the characteristics of everything Nightingale believed in: being responsible to your individual patients and accountable for your performance, being resilient and working to try to change the system,” she says.

That’s why Naylor believes nurses will play a pivotal role in fixing what to her are the most threatening healthcare problems facing the U.S. — the rapidly growing number of chronically ill elder patients and the disproportionate rate of healthcare expenditures among this population.

Since 1989, Naylor has led an interdisciplinary program of research designed to improve outcomes and reduce costs of care for vulnerable community-based elders.

These nurses recognize that people are re-hospitalized because of challenges that aren’t always health-related.

“In 1983, when Medicare started paying along diagnostic categories, or DRGs, older Americans were being discharged sicker and quicker than ever before in history. At the same time, there was no redesign of the health system,” Naylor says. “I participated in [U.S. Senate] hearings that looked at the impact of this policy change, and we determined that we had an increasing group of older adults for whom we had not created a safety net.”

She joined a team at the University of Pennsylvania that used evidence-based protocols on transitional care for low birth-weight infants. Naylor began to explore how the protocol could be adapted for older adults.

“We’ve been testing and refining the transitional care model for two decades,” Naylor says. “Master’s-prepared nurses work with patients identified at admission as high-risk elders, caring for them throughout their hospitalization to make sure nothing goes wrong and collaborating with them, their family members and all hospital team members. Then those same nurses will follow them home, be back in the home within 24 hours and go to their first primary-care visits.”

Naylor emphasizes that the model is a nurse-led and team-based.

“These nurses are engaging all health professionals to come up with a rational approach that will enable a patient to live a higher-quality life overall. They’re system-savvy, and they’re great communicators. They recognize that people are re-hospitalized because of challenges that aren’t always health-related.”

The evidence-based model has begun to influence national healthcare policy.

“We already know a great deal about how to avoid unnecessary hospitalizations, which have tremendous human costs, as well as financial ones,” Naylor says. “Even relatively minor adjustments could have major savings.”

Naylor helped get the Medicare Transitional Care Act introduced in the House and Senate, but the bill stalled there.

“It was not included in the final healthcare reform bill, but several provisions are included that will bring us closer to assuring better transitional care for older Americans,” she says. “They deserve it.”

Her concern for the individual’s dignity is reminiscent of Nightingale’s resolve.

“What I’ve tried to do is create an environment that allows terrific clinicians to be able to understand and realize what they’re capable of doing,” Naylor says. “Our work uses evidence to inform clinical practice and policy and doesn’t just accept something when it doesn’t work. Like Nightingale, we’re staying committed to translating our evidence to have impact.”

Note: Story published online at – errors introduced there are not mine.