Transitional Care Model (2011-2012)

University of Pennsylvania School of Nursing in collaboration with SEPA II PCMH (Patient Centered Medical Homes)

This grant supported a study that addressed the existing knowledge gap around care management for elders suffering from multiple coexisting conditions. With support from Jonas, the Betty Irene Moore Foundation and the Hillman Foundation, researchers built upon a multidisciplinary team’s extensive body of research examining the effectiveness of a nurse-led transitional care model that supports high risk older adults and their family caregivers during acute phases of chronic illness, and extended this model to include longitudinal care management for this population.


  • $200,000 from Jonas
  • $700,000 from Gordon & Betty Moore Foundation
  • $200,000 from Hillman Foundation