Naylor, Mary D.

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Curriculum Vitae MARY D. NAYLOR, PHD, RN Business Address University of Pennsylvania

School of Nursing 418 Curie Boulevard Claire M. Fagin Hall, RM341 Philadelphia, PA USA 19104-4217 Phone: 215-898-6088 Fax: 215-573-4225 Email: naylor@nursing.upenn.edu

Home Address Available Upon Request Social Security Number Available Upon Request Licensure PA License #: RN-182038-L Present Position Marian S. Ware Professor in Gerontology

University of Pennsylvania School of Nursing Philadelphia, PA

Education PHD 1982 University of Pennsylvania

Philadelphia, PA Major: Higher Education Administration

MSN 1973 University of Pennsylvania

Philadelphia, PA Major: Nursing

BSN 1971 Villanova University

Villanova, PA Major: Nursing

Faculty and Administrative Appointments

2015-2016 Presidential Scholar University of California San Francisco San Francisco, CA 2006-Present Director, NewCourtland Center for Transitions and Health University of Pennsylvania, School of Nursing Philadelphia, PA

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2002-Present Marian S. Ware Professor in Gerontology University of Pennsylvania, School of Nursing Philadelphia, PA 2000-Present Professor (with tenure) University of Pennsylvania, School of Nursing Philadelphia, PA 2000-2002 Ralston Endowed Term Chair University of Pennsylvania, School of Nursing Philadelphia, PA 1998-2004 Co-Faculty Director, Living Independently For Elders (LIFE) University of Pennsylvania, School of Nursing Philadelphia, PA 1998 Visiting Faculty, The John A. Hartford Foundation, Institute for Geriatric

Nursing, New York University, Division of Nursing Summer Fellowship for Post-Doctoral Fellows New York, NY

1997-2006 Associate Director, Center for Gerontologic Nursing Science University of Pennsylvania, School of Nursing Philadelphia, PA 1997 Visiting Scholar Boston College School of Nursing 1995-Present Faculty Director, Hillman Program University of Pennsylvania, School of Nursing Philadelphia, PA 1986-1998 Associate Dean and Director of Undergraduate Studies University of Pennsylvania, School of Nursing Philadelphia, PA 1991-2000 Associate Professor (with tenure) University of Pennsylvania, School of Nursing Secondary Faculty Appointment School of Arts and Sciences & the Wharton School University of Pennsylvania Philadelphia, PA 1993-Present Senior Fellow Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia, PA

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1992-1993 Legislative Health Policy Fellow Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia, PA 1986-1991 Assistant Professor University of Pennsylvania, School of Nursing Secondary Faculty Appointment School of Arts and Sciences University of Pennsylvania Philadelphia, PA 1985-1986 Professional Staff Member/W. K. Kellogg National Leadership Fellow U.S. Senate Special Committee on Aging Washington, DC 1985-1986 Chairman and Professor

Department of Nursing, College of Allied Health Sciences Associate Director of Nursing Department of Nursing Service, Thomas Jefferson University Hospital Thomas Jefferson University Philadelphia, PA

1979-1985 Chairman and Associate Professor Department of Nursing, College of Allied Health Sciences Assistant Director of Nursing Department of Nursing Service, Thomas Jefferson University Hospital Thomas Jefferson University Philadelphia, PA 1976-1979 Assistant Professor, Department of Nursing Thomas Jefferson University Philadelphia, PA 1973-1976 Instructor, Department of Nursing, College of Allied Health Sciences Thomas Jefferson University Philadelphia, PA 1971-1976 Staff Nurse / Head Nurse Bryn Mawr Hospital Bryn Mawr, PA

Appointments, Awards, and Honors

2017 Anna Reynvaan Lecturer, Academic Medical Center, Amsterdam University, Amsterdam, Netherlands

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2016 Distinguished Investigator Award, AcademyHealth 2016 Nurse Researcher Award, AONE Foundation 2015 Doris Schwartz Gerontological Nursing Research Award, Gerontological

Society of America 2015 Presidential Chair, Visiting Scholar, University of California, San

Francisco 2013 Anthony J. Jannetti Award for Extraordinary Contributions to Health

Care, Academy of Medical-Surgical Nurses 2012 Maxwell A. Pollack Award for Productive Aging, Gerontological Society

of America 2012 President’s Award, Friends of the National Institute of Nursing Research 2011 GE Healthcare-AACN Pioneering Spirit Award, American Association of

Critical-Care Nurses 2010 Policy Luminary Award, American Association of Colleges of Nursing 2010-2016 Member, Medicare Payment Advisory Commission (MedPAC) 2009 The Episteme Award, Baxter International Foundation Sigma Theta Tau International 2009 Edward Henderson Award and State-of-the-Art Lecture

American Geriatrics Society 2008 Frances Payne Bolton Award

Friends of the National Institute of Nursing Research 2006 Member, Quality Alliance Steering Committee 2005 Fellow, National Academy of Medicine

2004 McCann Scholar Award, Outstanding Mentorship in Nursing Joy McCann Foundation 2003 Claire Fagin Distinguished Researcher Award University of Pennsylvania, School of Nursing 2002 Nursing Research Award, Heart Failure Society of America 2002 Marian S. Ware Endowed Chair in Gerontology 2001 Lenore Williams Award, University of Pennsylvania 2001 Fellow, American Heart Association 1999 Outstanding Alumna Award, Univ. of Pennsylvania, School of Nursing 1999 Ralston Endowed Term Chair, University of Pennsylvania 1996 Nightingale Award of Pennsylvania for Nursing Research 1995 Nursing Research Award, Pennsylvania Nurses Association 1995-1999 Killibrew Term Chair in Undergraduate Education 1990-1995 Killibrew-Censits Term Chair in Undergraduate Education 1986 Fellow, American Academy of Nursing 1986 Distinguished Alumna Award, Villanova University, College of Nursing 1983-1986 National Leadership Fellowship, W.K. Kellogg Foundation 1983 Phi Delta Kappa, National Honor Society for Education 1973 Sigma Theta Tau, National Honor Society of Nursing,

Distinguished Lecturer, 1988 - 1994 1973 Pi Lambda Theta, National Honor Society for Women in

Education

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Research Grants Naylor, M. (2015-2018). Site Principal Investigator Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence) Patient Centered Outcomes Research Institute (University of Kentucky/M. Williams) Total Costs: $14,908,541 Naylor, M. (2014-2019). Co-Investigator (Ulrich, C.M., Principal Investigator) Retention in Cancer Clinical Trials: Modeling Patient-Participants’ Risk-Benefit Assessments National Institutes of Health, National Cancer Institute (R01CA196131) Total Costs: $2,518,546 Naylor, M. (2015-2016). Co-Principal Investigator The Use of Policy Simulation in Making Decisions to Implement the Transitional Care Model Robert Wood Johnson Foundation (Stevens Institute, Rouse W.) Total Costs: $400,000 Naylor, M. (2014-2016). Principal Investigator Local Adaptations of the Transitional Care Model Robert Wood Johnson Foundation Total Costs: $299,923 Naylor, M. (2011-2014). Principal Investigator Effects of Patient Centered Medical Home Plus Transitional Care for Complex Older Adults Gordon & Betty Moore Foundation, the Jonas Center for Excellence, and the Alex & Rita Hillman Foundation Direct Costs: $1,037,691 Naylor, M. (2010-2016). Co-Investigator (Bowles, K.H., Principal Investigator) Decision Support: Optimizing Post Acute Referrals and Effect on Patient Outcomes National Institutes of Health, National Institute of Nursing Research, (R01NR07674) Direct Costs: $442,718 Naylor, M. (2009-2014). Principal Investigator Care Coordination Component Program The Marian S. Ware Alzheimer Program, University of Pennsylvania Total Costs: $1,200,000 Naylor, M. (2006-2012). Principal Investigator Health Related Quality of Life: Elders in Long-Term Care National Institutes of Health, National Institute on Aging, (R01AG025524) Direct Costs: $2,343,973

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Naylor, M. (2006-2009). Principal Investigator Translating Research Into Practice: Transitional Care for Elders The John A. Hartford Foundation, Inc. Direct Costs: $447,867 Naylor, M. (2005-2015). National Program Director Interdisciplinary Nursing Quality Research Initiative The Robert Wood Johnson Foundation Direct Costs: N/A Naylor, M. (2005-2009). Principal Investigator Translating Research Into Practice: Expanding the Model of Care The Jacob and Valeria Langeloth Foundation Direct Costs: $164,591 Naylor, M. (2005-2011). Principal Investigator Hospital to Home: Cognitively Impaired Elders and their Caregivers National Institutes of Health, National Institute on Aging, (R01AG023116) Direct Costs: $1,737,624 Naylor, M. (2005-2010). Co-Investigator (Bowles, K.H., Principal Investigator) Promoting Self-Care with Telehomecare: Impact on Outcomes National Institutes of Health, National Institute of Nursing Research, (R01NR008923) Direct Costs: $334,846 Naylor, M. (2005-2008). Co-Investigator (Casarett, D., Principal Investigator) Patients' and families' Home Care Service Priorities National Institutes of Health, National Cancer Institute, (R01CA109540) Direct Cost: $ 250,000 Naylor, M. (2004-2007). Principal Investigator Transitional Care Model for Elders The Jacob and Valeria Langeloth Foundation Direct Costs: $233,808 Naylor, M. (2004-2007). Principal Investigator Coordinating Care Between Hospital and Home: Translating Research into Practice, Phase I & II The Commonwealth Fund (2004-0068) Direct Costs: $473,235 Naylor, M. (2004-2009). Principal Investigator Hospital to Home: Cognitively Impaired Elders and their Caregivers The Marian S. Ware Alzheimer Program, University of Pennsylvania Direct Costs: $1,000,000

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Naylor, M. (2001-2003). Principal Investigator Assessing Health Related Quality of Life of Frail Elders Presbyterian Foundation for Philadelphia Direct Costs: $166,000 Naylor, M. (2002-2003). Principal Investigator Health Related Quality of Life of Frail Elders in Assisted Living Facilities University of Pennsylvania School of Nursing, Center for Health Outcomes (NIH / NINR, Aiken, L., P30NR05043) Direct Costs: $10,000 Naylor, M. (2001-2005). Co-Investigator (Bowles, K.H., Principal Investigator) Factors to Support Effective Discharge Decision Making National Institutes of Health, National Institute of Nursing Research, (R01NR07674) Direct Costs: $573,750 Naylor, M. (2000-2004). Co-Investigator (Jessup, M., Principal Investigator) Clinical and Economic Effectiveness of a Technology-Driven Heart Failure Monitoring System Health Care Financing Administration, (18-C-91172/3) Direct Costs: $3,100,000 Naylor, M. (2000-2004). Co-Investigator (Schwartz, J.S., Principal Investigator) Physician-Nurse Co-Management of Elders with Heart Failure National Institutes of Health, National Institute of Nursing Research, (R01NR007616) Direct Costs: $750,000 Naylor, M. (2000-2001). Principal Investigator Transitional Care Needs of Hospitalized Elders and their Caregivers National Alzheimer's Disease Association, (1433-40190-04) Direct Costs: $144,000 Naylor, M. (2000-2001). Principal Investigator Assessing Health Related Quality of Life of Frail Elders Presbyterian Foundation for Philadelphia Direct Costs: $150,000 Naylor, M. (2000-2003). Site Principal Investigator Developing a Community-Based Model of Care for High Risk Individuals with Severe Disabilities The Inglis Foundation (Sub-granted from The Pew Charitable Trusts) Direct Costs: $555,000 Naylor, M. (1999-2001). Principal Investigator Pace-Research: Integration of Clinical Research Information Systems for Measuring Health and Quality of Life for Frail Elders Presbyterian Foundation for Philadelphia Direct Costs: $50,000

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Naylor, M. (1998-1999). Principal Investigator Measuring Health Status and Quality of Life of Frail Elders Presbyterian Foundation for Philadelphia Direct Costs: $50,000 Naylor, M. (1997-1998). Principal Investigator Individualized Care of Patients with Alzheimer’s Disease and Their Caregivers: A Pilot Study Frank Morgan Jones Fund Direct Costs: $9,000 Naylor, M. (1996-2000). Principal Investigator Home Follow-Up of Elderly Patients with Heart Failure National Institutes of Health, National Institute of Nursing Research, (R01NR04315) Direct Costs: $1,580,166 Naylor, M. (1996-1999). Co-Investigator, Site PI (Brooten, D., PI) Nurse Practice Functions, Patient Problems, and Outcomes National Institutes of Health, National Institute of Nursing Research Direct Costs: $989,265 Naylor, M. (1995-1996). Principal Investigator Home Follow-Up of Elderly Patients with Heart Failure: A Pilot Study Frank Morgan Jones Fund, Direct Costs: $5,000 University of Pennsylvania, University Research Foundation Direct Costs: $15,000 Naylor, M. (1992-1996). Principal Investigator Comprehensive Discharge Planning for Hospitalized Elderly National Institutes of Health, National Institute of Nursing Research, (R01NR02095) Direct Costs: $1,134,724 Naylor, M. (1991-1992). Principal Investigator Comprehensive Discharge Planning and Home Follow-Up of Hospitalized Elderly Frank Morgan Jones Fund Direct Costs: $5,000 Naylor, M. (1989-1992). Principal Investigator Comprehensive Discharge Planning for Hospitalized Elderly National Institutes of Health, National Center for Nursing Research, (R01NR02095) Direct Costs: $584,227 Naylor, M. (1988-1989). Principal Investigator Comprehensive Discharge Planning for Hospitalized Elderly

Center for the Study of Aging, University of Pennsylvania (Direct Costs: $4,959) Frank Morgan Jones Fund (Direct Costs: $5,000) University Research Foundation, Penn (Direct Costs: $5,000)

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Other Selected Sponsored Projects Naylor, M.D. (2015-2018). Center Director Redefining the Future of Health Transitions NewCourtland Senior Services Total Costs: $589,289 Naylor, M.D. (2007[8]-2019). Program Director Individualized Care for At-Risk Older Adults National Institutes of Health, National Institute of Nursing Research, (T32NR009356) Total Costs: $2,106,035 Naylor, M.D., Johnson. J., & Lewis, B. (2003-2007). Program Director Center for Interdisciplinary Geriatric Health Care Research The RAND Corporation (Sub-granted by The John A. Hartford Foundation) Total Costs: $200,000 Naylor, M. (2003-2004). Principal Investigator Living Independently for Elders (LIFE) Franklin Health Trust Award Direct Costs: $65.000 Strumpf, N., Evans, L., & Naylor, M. (2001-2006). Co-Program Director Center for Gerontologic Nursing Excellence The John A Hartford Foundation Total Costs: $1,331,250 Buhler-Wilkerson, K. & Naylor, M. (2001-2002). Co-Principal Investigator Living Independently for Elders (LIFE) The Connolly Foundation Direct Costs: $300,000 Buhler-Wilkerson, K., & Naylor, M. (2000-2001). Co-Principal Investigator Living Independently for Elders (LIFE): Improving Quality of Life of Frail Elders in West Philadelphia Pew Charitable Trust Direct Costs: $150,000 Buhler-Wilkerson, K., & Naylor, M. (1998-1999). Co-Principal Investigator Development of a Second Adult Day Health Center for the LIFE Program The Presbyterian Foundation for Philadelphia Direct Costs: $50,000 Buhler-Wilkerson, K., & Naylor, M. (1997-2002). Co-Principal Investigator Establishing an Alzheimer’s Center for the LIFE Program The Ladies Aide Society of the Presbyterian Foundation for Philadelphia Direct Costs: $200,000

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Buhler-Wilkerson, K., & Naylor, M. (1997-2000). Co-Principal Investigator Development and Implementation of a Program of Mental Health Promotion and Awareness for Participants of the LIFE Program Van Ameringen Foundation, Inc. Direct Costs: $300,000 Buhler-Wilkerson, K., & Naylor, M. (1996-1999). Co-Principal Investigator Bringing the Program of All-inclusive Care for the Elderly (PACE) to the Frail Elderly in West Philadelphia The Connelly Foundation Direct Costs: $300,000 Buhler-Wilkerson, K., & Naylor, M. (1995-1996). Co-Principal Investigator Teaching Nursing Home Ralston House Board of Directors Direct Costs: $100,000

Presentations (last 5 years)

10 June 2017. “Reducing Hospital Readmissions—Effective Transitions Matter: Transitional Care Model – improving diabetes outcomes for vulnerable populations.” American Diabetes Association 77th Scientific Sessions, San Diego, CA. 11 May 2017. “The Transitional Care Model: A Journey from Evidence to Impact.” 18th Anna Reynvaan Lecturer, Academic Medical Center, Amsterdam University, Amsterdam, Netherlands. 5 April 2017. “An Odyssey of Nursing’s Leadership in Improving the Care of Older Adults.” 9th Annual Norman and Alicia Volk Lecture in Geriatric Nursing, New York University, New York, NY. 16 February 2017. “Transitional Care Model. Reducing Hospital Readmissions – Let us show you how and why.” Anthem, Virtual Webinar. 21 October 2016. “Transitional Care Model: A Journey from Evidence to Impact.” University of Kentucky, Department of Medicine Grand Rounds, Lexington, KY. 20 September 2016. “The Relationship of Transitional Care to Population Health & System Redesign.” Leading Health Care Reform by Building Accountable Communities conference, Southwestern Vermont Health Care, West Dover, VT. 26 August 2016. “Health Related Quality of Life of Long-Term Care Recipients.” 2nd Annual Advances in Post-Acute and Long-Term Care conference, Florida State University, School of Medicine, Tallahassee, FL.

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6 June 2016. “Transitional Care Model: A Journey from Evidence to Impact.” 2nd Annual Innovations in Geriatric Nursing Care conference, UCSF John A. Hartford Foundation Center for Gerontological Nursing Excellence, San Francisco, CA. 19 April 2016. “Transitional Care Model: A Journey from Evidence to Impact.” 2016 Annual NICHE conference, Chicago, IL. 28 January 2016. “Transitional Care: A Health System’s Ethical Responsibility in an Aging Society.” 18th Annual Reza K. Gandjei Memorial Lecture. University of California San Francisco, School of Medicine, San Francisco, CA. 19 November 2015. “Transitional Care Model: A Journey from Evidence to Impact.” Doris Schwartz Gerontological Nursing Research Award and Lecture, Gerontological Society of America, Orlando, FL. 19 November 2015. “Informal Caregiving of Older Adults: Next Steps in Research.” Caregiving: Strategies, Implications, and Outcomes--Symposium, Gerontological Society of America, Orlando, FL. 29 October 2015. “2015 Presidential Chair Lecture: Transitional Care.” University of California San Francisco, San Francisco, CA. 5 October 2015. “Evidence Contributing to Healthcare System Redesign.” Value Institute Symposium, Transitional Care: Bridging the Gap for At Risk Populations, Christiana Care Health System, Newark, DE. 25 September 2015. “One Journey to Population Health: Research Leading to System Redesign.” 12th Annual, Achieving Excellence in Clinical Research, Advocate Health Care, Oak Brook, IL. 17 July 2015. “Building the Health Workforce as We Transform the Delivery System.” The Commonwealth Fund and Nuffield Trust, 15th International Meeting on the Quality and Efficiency of Health Care, Bagshot, Surrey, United Kingdom. 23 June 2015. Keynote: “Transitional Care Model: A Journey From Evidence To Impact.” Cracking the Code on Healthcare SPOTLIGHT event, Improving Care Transitions, NorthStar Network, Rochester, NY. 20 May 2015. Keynote: “Transitional Care Model: A Journey From Evidence To Impact.” University of Minnesota School of Nursing and School of Public Health Center on Aging/MAGEC, Minneapolis, MN. 19 May 2015. Keynote: “From Evidence to Impact: An Interdisciplinary Approach to High Value Healthcare.” The Jeffrey Paul and Grace Kathryn Feather Endowed Lectureship Series, Lehigh Valley Health Network, Allentown, PA.

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1 May 2015. Keynote: “From Evidence to Impact: Transitional Care for Chronically Ill Older Adults.” The 30th Management and Leadership Conference, National Hospice and Palliative Care Organization, National Harbor, MD. 17 April 2015. Keynote: “From Evidence to Impact: An Interdisciplinary Approach to High Value Healthcare.” 21st Florence Cellar Conference on Aging, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH. 25 February 2015. Keynote: “From Evidence to Impact: An Interdisciplinary Approach to High Value Healthcare.” 10th Annual Buckley Scholars’ Lecture, Adelphi University, Garden City, NY. 18 February 2015. Presenter: “Project ACHIEVE.” Meet the Experts series, AcademyHealth, first IRGNI sponsored webinar. 3 February 2015. Presenter: “Transitions of Care in People with Multiple Chronic Conditions.” HMO Research Network, OAICs Aging Initiative, Webinar. 12 December 2014. Presenter: “Collaborative Evidence-based Best Practices.” CMS/Social Work Research, Webinar. 2 December 2014. “Care Transitions: Evidence-based best practices for Case Managers.” Commission for Case Manager Certification, CMLearning Network, Webinar. 11 November 2014. Presenter: “A Model for Interdisciplinary Research with High Impact.” 3rd Annual Nursing Research Conference, Hospital of the University of Pennsylvania, Philadelphia, PA. 22 October 2014. Keynote: “The Transitional Care Model: A Journey From Evidence to Impact.” Brooks Rehabilitation, 6th Annual Research Day, Jacksonville, FL. 29 September 2014. Keynote: “Transitional Care: Designing Solutions that Maximize on the Evidence.” Healthcare Leadership Forum, Leveraging Evidence Across the Care Continuum, Chicago, IL. 20 May 2014. Presenter: “From Evidence to Impact: An Interdisciplinary Journey To Achieving Quality.” American Association of Colleges of Nursing, Graduate Nursing Student Academy, Webinar. 13 May 2014. Keynote: “The Transitional Care Model: A Journey From Evidence to Impact.” Joint Research in Patient Services Colloquium and Health Services Research (HSR) Matrix Community Seminar, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH. 7 May 2014. Faculty: “End-of-Life and Palliative Care Workshop.” National Institute of Nursing Research, Bethesda, MD.

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15 January 2014. Presenter: “Physician-Nurse Collaboration on Research in the 21st Century.” National Cancer Institute, Process of Care Research Branch, Health Care Team Lecture Series, Rockville, MD. 22 November 2013. Maxwell A. Pollack Lecture: “Transitional Care Model: A Journey From Evidence to Impact.” Gerontological Society of American, New Orleans, LA. 15 November 2013. Keynote: “Transitional Care Model: Evidence to Impact-Tackling Care Coordination.” University of Illinois at Chicago, 16th Annual Power of Nursing Leadership, Chicago, IL. 5 November 2013. Presenter: “Session VII: Managing Transitions.” Leading Healthcare Practices and Training: Defining and Delivering Disability-Competent Care, Disability Practice Institute, IHI, and the Lewin Group, Webinar. 20 October 2013. Panelist: “Transforming Patient Care: Aligning Interprofessional Education with Clinical Practice Redesign.” Institute of Medicine, 43rd Annual Meeting, Washington, DC. 11 October 2013. Keynote: “Transitional Care Model: A Journey From Evidence to Impact.” COPD Readmissions Summit, COPD Foundation, Washington, DC. 27 September 2013. Keynote: “The Transitional Care Model: A Journey From Evidence to Impact.” Academy of Medical-Surgical Nurses, 22nd Annual Convention, Nashville, TN. 5 September 2013. Keynote: “The Transitional Care Model: A Journey From Evidence to Impact.” WellSpan Annual Quality Forum, Gettysburg, PA. 12 July 2013. Presenter: “Setting the Stage—Current State of Evidence”. PCORI Transitional Care Workgroup Meeting, Washington, DC. 1 June 2013. Keynote: “Invest in Your Health: Optimize Your Quality of Life”. Welcome to Aging Well, A Health and Wellness Educational Event, Intermed Health and Aetna, Portland, ME. 14 May 2013. Panelist: “Transitions and Family Caregiving.” Transitions in Care 2.0: Family Caregivers and Systems Change. United Hospital Fund, New York, NY. 10 May 2013. Grand Rounds: “Transitional Care Model: Evidence Based Transitional Care for Chronically Ill Older Adults.” Cedars-Sinai Medical Center, Medicine Grand Rounds, Los Angeles, CA. 17 April 2013. Keynote: “The Transitional Care Model: A Journey From Evidence to Impact.” 16th Annual Stanley P. Mayers Endowed Lecture, The Penn State University, University Park, PA.

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19 March 2013. Faculty: “Transitional Care Model,” Diving into the Readmissions Toolbox: AHRQ Data Query Tool & Drill Down into Two Evidence-Based Interventions, AHRQ Webinar. 3 April 2013. Grand Rounds: “Transitional Care: Improving Health Care Quality.” Winchester Medical Center, Winchester, VA. 28 February 2013. Faculty: “The Transitional Care Model.” Care Management & Care Coordination Expert Office Hour, Safety Net Medical Home Initiative’s Office Hour series. Qualis Health, Webinar. 13 February 2013. Panelist: Care About Your Care. The Robert Wood Johnson Foundation, Washington, DC. 29 January 2013. Faculty: “The Transitional Care Model.” VHA PACT Ambulatory Care ICU Project, Webinar. 5 December 2012. Panelist: NTOCC National Transitions of Care Summit. “Leading Models in Transitions of Care”, section: “The Transitional Care Model”. Washington, DC. 27 November 2012. “Transitional Care Model: Translating Research into Practice and Policy.” Grand Rounds, University of Chicago, Chicago, IL. 20 November 2012. Faculty: “The Importance of Transitional Care: Review of Nine Interventions to Reduce Avoidable Readmissions – Which One is Best for Your CVE Community?” AHRQ Learning Network for Chartered Value Exchanges, Webinar. 18 November 2012. Symposium: “Health Related Quality of Life among Long-term Services and Support Recipients: A Longitudinal Analysis”. The Gerontological Society of America’s 64th Annual Scientific Meeting. San Diego, CA. 27 June 2012. Faculty: “Healthcare Transitions and Coordination: Early Readmission, Effectiveness, Economics. Part 1. Transitions in Patient Care.” Improvement Science Research Network, Web Seminar. 13 June 2012. Panelist: “Improving Health Care Quality and Patient Health”. Panel: Marilyn Tavener (moderator), Margaret Flinter, Kristi Henderson, Mary Naylor. The White House and Department of Health and Human Services, Washington, DC.

Journal Articles

Tisminetzky M, Bayliss EA, Magaziner JS, Allore HG, Anzuoni K, Boyd CM, Gill TM, Go AS, Greenspan SL, Hanson LR, Hornbrook MC, Kitzman DW, Larson EB, Naylor MD, Shirley BE, Tai-Seale M, Teri L, Tinetti ME, Whitson HE, Gurwitz JH. (2017). Research Priorities to Advance the Health and Health Care of Older Adults with Multiple Chronic Conditions. Journal of the American Geriatrics Society, 2017 May 26. doi: 10.1111/jgs.14943. [Epub ahead of print] PMID: 28555750

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Chase JD, Hirschman KB, Hanlon AL, Huang L, Bowles KH, Naylor MD. (2017). Physical Functioning Among Older Adults New to Long-Term Services and Supports. Gerontologist, 2017 May 25. doi: 10.1093/geront/gnx082. [Epub ahead of print] PMID:28549107 Naylor MD, Shaid EC, Carpenter D, Gass B, Levine C, Li J, Malley A, McCauley K, Nguyen HO, Watson H, Brock J, Mittman B, Jack B, Mitchell S, Callicoatte B, Schall J, Williams MV. (2017). Components of Comprehensive and Effective Transitional Care. Journal of the American Geriatrics Society, 2017 Apr 3. doi: 10.1111/jgs.14782. [Epub ahead of print] PMID:28369722 O’Connor, M, Hanlon AL, Mauer E, Meghani S, Masterson-Creber R, Marcantonio S, Coburn K, Van Cleave J, Davitt J, Riegel B, Bowles KH, Keim S, Greenberg SA, Sefcik JS, Topaz M, Kong D, Naylor MD. (2017). Identifying distinct risk profiles to predict adverse events among community-dwelling older adults. Geriatric Nursing, 2017 May 4. pii: S0197-4572(17)30067-8. doi: 10.1016/j.gerinurse.2017.03.013. [Epub ahead of print]. PMID: 28479081 Shaid EC, Hirschman KB, Byrnes MB, Naylor MD. (2017). Using Root-Cause Analysis to Change Practice. Urologic Nursing, 37(2):75-80, 100. doi:10.7257/1053-816X.2017.37.2.75. Hirschman KB, Shaid E, Bixby MB, Badolato DJ, Barg R, Byrnes MB, Byrnes R, Streletz D, Stretton J, Naylor MD. (2017). Transitional Care in the Patient-Centered Medical Home: Lessons in Adaptation. Journal for Healthcare Quality, 39(2):67-77. doi: 10.1097/01.JHQ.0000462685.78253.e8. Sefcik JS, Petrovsky D, Streur M, Toles M, O’Connor M, Ulrich C, Marcantonio S, Coburn K, Naylor MD, Moriarty H. (2016). “In our corner”: A Qualitative Descriptive Study of Patient Engagement in a Community-based Care Coordination Program. Clinical Nursing Research, 2016 Dec 1:1054773816685746. doi: 10.1177/1054773816685746. [Epub ahead of print]. PMID: 28038504 Van Cleave JH, Egleston BL, Abbott KM, Hirschman KB, Rao A, Naylor MD. (2016). Multiple chronic conditions and hospitalizations among recipients of long-term services and supports. Nursing Research, 65(6):425-434. PMID: 27801713 Zubritsky C, Abbott KM, Hirschman KB, Hanlon A, Bowles KH, Naylor MD. (2016). Changes over time in emotional status among older adults new to receiving long-term services and supports. Journal of Best Practices in Mental Health, 12(2):63-80. Naylor M, Berlinger N. (2016). Transitional Care: A Priority for Health Care Organizational Ethics. Special Report: Nurses at the Table: Nursing, Ethics, and Health Policy. The Hastings Center Report, 46(5):S39-S42. doi: 10.1002/hast.631. PMID: 27649919 Bowles KH, Ratcliffe S, Potashnik S, Topaz M, Holmes J, Shih N-W, Naylor MD. (2016). H3IT Special Topic: Using electronic case summaries to elicit multi-disciplinary expert knowledge about referrals to post-acute care. Applied Clinical Informatics, 7(2):368-79. doi: 10.4338/ACI-2015-11-RA-0161.

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Naylor MD, Hirschman KB, Hanlon AL, Bowles KH, Bradway C, McCauley KM, Pauly MV. (2016). Effects of alternative interventions among hospitalized, cognitively impaired older adults. Journal of Comparative Effectiveness Research, 5(3):259-72. doi: 10.2217/cer-2015-0009. Toles M, Colon-Emeric C, Naylor MD, Barroso J, Anderson RA. (2016). Transitional care in skilled nursing facilities: a multiple case study. BMC Health Services Research, 16(1):186. doi: 10.1186/s12913-016-1427-1. Van Cleave JH, Smith-Howell E, Naylor MD. (2016). Achieving a high-quality cancer care delivery system for older adults: Innovative models of care. Seminars in Oncology Nursing, 32(2):122-33. doi: 10.1016/j.soncn.2016.02.006. Li J, Brock J, Jack B, Mittman B, Naylor M, Sorra J, Mays G, Williams MV; Project ACHIEVE Team. (2016). Project ACHIEVE – using implementation research to guide the evaluation of transitional care effectiveness. BMC Health Services Research. 16(1):70. doi: 10.1186/s12913-016-1312-y. PMID: 26896024 Naylor MD, Hirschman KB, Hanlon AL, Abbott KM, Bowles KH, Foust J, Shah S, Zubritsky C. (2016). Factors associated with changes in perceived quality of life among elderly recipients of long term services and supports. Journal of the American Medical Directors Association. 17(1):44-52. doi: 10.1016/j.jamda.2015.07.019. Epub 2015 Sep 26. PubMed PMID: 26412018; PubMed Central PMCID: PMC4696886. Toles M, Moriarty H, Coburn K, Marcantonio S, Hanlon A, Mauer E, Fisher P, O’Connor M, Ulrich C, Naylor MD. (2015). Managing chronic illness: Nursing contact and participant enrollment in a Medicare care coordination demonstration program. Journal of Applied Gerontology. 2015 Aug 31. pii: 0733464815602115. [Epub ahead of print] doi: 10.1177/0733464815602115 Hirschman K, Shaid E, McCauley K, Pauly M, Naylor M. (2015). Continuity of Care: The Transitional Care Model. OJIN: The Online Journal of Issues in Nursing, 20(2):1. doi: 10.3912/OJIN.Vol20No03Man01 Lamb G, Newhouse R, Beverly C, Toney DA, Cropley S, Weaver CA, Kurtzman E, Zazworsky D, Rantz M, Zierler B, Naylor M, Reinhard S, Sullivan C, Czubaruk K, Weston M, Dailey M, Peterson C; Task Force Members. (2015). Policy agenda for nurse-led care coordination. Nursing Outlook, 63(4):521-530. Hirschman K, Shaid E, Bixby M, Badolato D, Barg R, Byrnes MB, Byrnes R, Streletz D, Stretton J, Naylor M. (2017). Transitional care in the Patient Centered Medical Home: Lessons in adaptation. Journal for Healthcare Quality, 39(2):67-77. doi: 10.1097/01.JHQ.0000462685.78253.e8. [Epub ahead of print, 2015 Apr 9]. O’Connor M, Hanlon A, Naylor MD, Bowles KH. (2015). The impact of home health length of stay and number of skilled nursing visits on hospitalization among medicare-reimbursed skilled

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home health beneficiaries. Research in Nursing & Health, 38(4):257-267. doi: 10.1002/nur.21665. Epub 2015 May 19. Naylor MD, Kurtzman ET, Miller EA, Nadash P, Fitzgerald P. (2015). An Assessment of State-Led Reform of Long Term Service and Supports. Journal of Health Politics, Policy and Law, 40(3):531-574. doi: 10.1215/03616878-2888460. Epub 2015 Feb 19. McCauley K, Bradway C, Hirschman KB, Naylor MD. (2014). Studying Nursing Interventions in Acutely Ill Cognitively Impaired Older Adults. American Journal of Nursing, 114(10):44-52. PubMed PMID: 25251126; PubMed Central PMCID: PMC4662056 Naylor MD, Marcille J. (2014). Managing the transition from the hospital. Managed Care, 23(6):27-30. Tocchi C, Dixon J, Naylor M, Jeon S, McCorkle R. (2014). Development of a Frailty Measure for Older Adults: The Frailty Index for Elders. Journal of Nursing Measurement, 22(2):223-240. Naylor MD, Hirschman KB, Hanlon AL, Bowles KH, Bradway C, McCauley KM, Pauly MV. (2014). Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults. Journal of Comparative Effectiveness Research, 3(3):245-257. doi: 10.2217/cer.14.14. Shankar KN, Hirschman KB, Hanlon AL, Naylor MD. (2014). Burden among Caregivers of Elders who were Cognitively Impaired at the time of Hospitalization: A Cross-Sectional Analysis. Journal of the American Geriatrics Society, Feb;62(2):276-84. doi: 10.1111/jgs.12657. Epub 2014 Feb 6. PMID: 24502827. Toles M, Anderson RA, Massing M, Naylor MD, Jackson E, Peacock-Hinton S, Colon-Emeric C. (2014). Restarting the Cycle: Incidence and Predictors of First Acute Care Use After Nursing Home Discharge. Journal of the American Geriatrics Society. doi: 10.1111/jgs.12602. Hurria A, Naylor M, Cohen H. (2013). Improving the Quality of Cancer Care in an Aging Population: Recommendations From an IOM Report. JAMA, 310(17):1795-1796. doi:10.1001/jama.2013.280416. Meghani S, Buck HG, Dickson V, Hammer, MJ, Rabelo-Silva E, Clark RA, Naylor MD. (2013). The Conceptualization and Measurement of Comorbidity: An Integrative Review of the Interprofessional Literature. Nursing Research and Practice, Article ID 192782, doi:10.1155/2013/192782. Bradway C, Bixby MB, Hirschman KB, McCauley K, Naylor MD. (2014). Case study: Transitional care for a patient with benign prostatic hyperplasia and recurrent urinary tract infections. Urologic Nursing, 33(4):177-179, 200.

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Naylor MD, Hirschman KB, O’Connor M, Barg R, Pauly MV. (2013). Engaging older adults in their transitional care: What more needs to be done? Journal of Comparative Effectiveness Research, 2(5):457-468. Cipriano PF, Bowles KH, Dailey M, Dykes P, Lamb G, Naylor M. (2013). The importance of health information technology in care coordination and transitional care. Nursing Outlook, 61(6):475-489.

Van Cleave JH, Trotta RL, Lysaght S, Steis MR, Lorenz RA, Naylor MD. (2013). Comorbidities in the Context of Care Transitions. Advances in Nursing Science, 36(2):E1-E13, April/June. doi: 10.1097/ANS.0b013e318290207d Bowles KH, Potashnik S, Ratcliffe SJ, Rosenberg M, Shih N-W, Topaz M, Holmes JH, Naylor MD. (2013). Conducting Research Using the Electronic Health Record Across Multi-Hospital Systems: Semantic Harmonization Implications for Administrators. Journal of Nursing Administration, 43(6):355-360, June. doi: 10.1097/NNA.0b013e3182942c3c Naylor MD, Volpe EM, Lustig A, Kelley HJ, Melichar L, Pauly MV. (2013). Linkages between Nursing and the Quality of Patient Care: A Two Year Comparison. Medical Care, 51:S6-S14, April. doi: 10.1097/MLR.0b013e3182894848 Naylor MD, Lustig A, Kelley HJ, Volpe EM, Melichar L, Pauly MV. (2013). Introduction: The Interdisciplinary Nursing Quality Research Initiative. Medical Care, 51:S1-S5, April. doi: 10.1097/MLR.0b013e31827dc3ab Naylor MD, Bowles KH, McCauley KM, Maccoy MC, Maislin G, Pauly MV, Krakauer R. (2013). High-value transitional care: translation of research into practice. J Eval Clin Pract, 19(5):727-733. [Epub first online 16 MAR 2011]. doi: 10.1111/j.1365-2753.2011.01659.x Working Group on Health Outcomes for Older Persons with Multiple Chronic Conditions. (2012). Universal health outcome measures for older persons with multiple chronic conditions. J Am Geriatr Soc. Dec;60(12): 2333-41. doi: 10.1111/j.1532-5415.2012.04240.x. Epub 2012 Nov 29. Buck HG, Meghani S, Prvu Bettger JA, Byun E, Fachko MJ, O’Connor M, Tocchi C, Naylor M. (2012). The Use of Comorbidities Among Adults Experiencing Care Transitions: A Systematic Review and Evolutionary Analysis of Empirical Literature. Chronic Illness. Dec;8(4):278-295. doi: 10.1177/1742395312444741. Epub 2012 Apr 18. Toles MP, Abbott KM, Hirschman KB, Naylor MD. (2012). Transitions in care among older adults receiving long-term services and supports. J Gerontol Nurs. 2012 Nov;38(11):40-47. doi: 10.3928/00989134-20121003-04. Epub 2012 Oct 15. PMID: 23066681 Naylor MD, Karlawish JH, Arnold SE, Khachaturian AS, Khachaturian ZS, Lee VM, Baumgart M, Banerjee S, Beck C, Blennow K, Brookmeyer R, Brunden KR, Buckwalter KC, Comer M, Covinsky K, Feinberg LF, Frisoni G, Green C, Guimaraes RM, Gwyther LP, Hefti FF, Hutton M, Kawas C, Kent DM, Kuller L, Langa KM, Mahley RW, Maslow K, Masters

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CL, Meier DE, Neumann PJ, Paul SM, Petersen RC, Sager MA, Sano M, Schenk D, Soares H, Sperling RA, Stahl SM, van Deerlin V, Stern Y, Weir D, Wolk DA, Trojanowski JQ. (2012). Advancing Alzheimer's disease diagnosis, treatment, and care: recommendations from the Ware Invitational Summit. Alzheimers Dement, 2012 Sep;8(5):445-452. doi: 10.1016/j.jalz.2012.08.001. PMID: 22959699 Zubritsky C, Abbott KM, Hirschman KB, Bowles KH, Foust JB, Naylor MD. (2012). Health-related Quality of Life: Expanding a Conceptual Framework to Include Older Adults Who Receive Long-term Services and Supports. Gerontologist, 53(2):205-211. [Epub ahead of print: 2012 Aug 2] PMID: 22859435 Trojanowski JQ, Arnold SE, Karlawish JH, Naylor MD, Brunden KR, Lee VM-Y. (2012). A model for improving the treatment and care of Alzheimer patients through interdisciplinary research. Alzheimers Dement. Nov;8(6):564-73. doi: 10.1016/j.jalz.2011.08.005. PMID: 23102127 Bettger JP, Sochalski JA, Foust JB, Zubritsky CD, Hirschman KB, Abbott KM, Naylor MD. (2012). Measuring nursing care time and tasks in long-term services and supports: One size does not fit all. Journal of Nursing Research, Sep; 20(3):159-68. Naylor MD, Kurtzman ET, Grabowski DC, Harrington C, McClellan M, Reinhard SC. (2012). Unintended consequences of steps to cut readmissions and reform payment may threaten care of vulnerable older adults. Health Affairs, Jul; 31(7):1623-32. Bradway C, Trotta R, Bixby MB, McPartland E, Wollman MC, Kapustka H, McCauley K, Naylor MD. (2012). A qualitative analysis of an advanced practice nurse-directed Transitional Care Model intervention. The Gerontologist, Jun; 52(3):394-407. PMID: 21908805 Naylor MD. (2012). Advancing high value transitional care: the central role of nursing and its leadership. Nursing Administration Quarterly, Apr;36(2):115-26. PMID: 22407204 Foust JB, Naylor MD, Bixby MB, Ratcliffe SJ. (2012). Medication problems occurring at hospital discharge among older adults with heart failure. Research in Gerontological Nursing; Jan; 5(1):25-33. doi: 10.3928/19404921-20111206-04. Epub 2011 Dec 29. PMID: 22224903 Hirschman KB, Abbott KM, Hanlon AL, Prvu Bettger J, Naylor MD. 2012. What factors are associated with having an advance directive among older adults who are new to long term care services? J Am Med Dir Assoc. Jan;13(1):82.e7-11. doi: 10.1016/j.jamda.2010.12.010. Epub 2011 Feb 26. PMID: 21450235 Bowles KH, Hanlon AL, Glick HA, Naylor MD, O'Connor M, Riegel B, Shih NW, Weiner MG. (2011). Clinical effectiveness, access to, and satisfaction with care using a telehomecare substitution intervention: a randomized controlled trial. International Journal of Telemedicine and Applications. 2011:540138. Epub 2011 Dec 1. PMID: 22187551; PMCID: PMC3236461

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Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. (2011). THE CARE SPAN-- The Importance of Transitional Care in Achieving Health Reform. Health Affairs, 30(4):746-754. PMID: 21471497 Hirschman KB, Paik HH, Pines J, McCusker CM, Naylor MD, Hollander JE. (2011). Cognitive Impairment among Older Adults in the Emergency Department. Western Journal of Emergency Medicine, 12(1):56-62. PMID: 21691473 Naylor MD and Sochalski JA. (2010). Scaling Up: Bringing the Transitional Care Model into the Mainstream. The Commonwealth Fund, Issue Brief, November 2010. Bowles KH, Riegel B, Weiner MG, Glick H, Naylor MD. (2010). The Effect of Telehealth on Heart Failure Self Care. Journal of the American Medical Informatics Association, 1-5. Naylor MD and Kurtzman ET. (2010) The role of nurse practitioners in reinventing primary care. Health Affairs (Millwood), 29(5):893-9. Trojanowski JQ, Arnold SE, Karlawish JH, Brunden K, Cary M, Davatzikos C, Detre J, Gaulton G, Grossman M, Hurtig H, Kathryn Jedrziewski K, McCluskey L, Naylor MD, Polsky D, Schellenberg GD, Siderowf A, Shaw LM, Van Deerlin V, Wang L-S, Werner R, Xie SX, Lee V M-Y. (2010) Design of Comprehensive Alzheimer’s Disease Centers to Address Unmet National Needs. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 6(2):150-155. Naylor MD, Feldman P, Keating S, Koren MJ, Kurtzman ET, Maccoy M, Krakauer R. (2009). Translating Research Into Practice: Transitional Care for Older Adults. Journal of Evaluation in Clinical Practice, 15:1164-1170. Naylor MD, Kurtzman ET, Pauly MV. (2009) Transitions of elders between long-term care and hospitals. Policy, Politics, & Nursing Practice, 10(3):187-194. Bowles KH, Holmes JH, Ratcliffe S, Liberatore M, Nydick R, Naylor MD. (2009). Factors Identified by Experts to Support Decision Making for Post Acute Referrals. Nursing Research, 58(2):115-122. Sochalski J, Jaarsma T, Krumholz HM, Laramee A, McMurray JJ, Naylor MD, Rich MW, Riegel B, Stewart S. (2009). What works in chronic care management: the case of heart failure. Health Affairs (Millwood), 28(1):179-89. Casarett DJ, Fishman JM, Lu HL, O'Dwyer PJ, Barg FK, Naylor MD, Asch DA. (2009). The terrible choice: re-evaluating hospice eligibility criteria for cancer. J Clin Oncol., 27(6):953-9. Naylor, MD and Keating SK. (2008). Transitional Care: Movement from one care setting to another. American Journal of Nursing, 108(S9):58-63.

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Casarett D, Fishman J, O'Dwyer P, Barg F, Naylor MD, Asch D. (2008). How should we design supportive cancer care? The patient’s perspective. Journal of Clinical Oncology, 26(8):1296-1301. Bowles KH, Ratcliffe SJ, Holmes JH, Liberatore M, Nydick R, Naylor MD. (2008). Post-acute referral decisions made by multidisciplinary experts compared to hospital clinicians and the patients' 12-week outcomes. Medical Care, 46(2):158-66. Alexander KP, Newby LK, Armstrong PW, Cannon CP, Gibler WB, Rich MW, Van de Werf F, White HD, Weaver WD, Naylor MD, Gore JM, Krumholz HM, Ohman EM; American Heart Association Council on Clinical Cardiology; Society of Geriatric Cardiology. (2007) Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation, 115(19):2570-89. Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, Van de Werf F, White HD, Weaver WD, Naylor MD, Gore JM, Krumholz HM, Ohman EM; American Heart Association Council on Clinical Cardiology; Society of Geriatric Cardiology. (2007) Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation, 115(19):2549-69. Naylor, MD, Hirschman KB, Bowles KH, Bixby MB, Konick-McMahan J, Stephens C. (2007). Care Coordination for Cognitively Impaired Older Adults and Their Caregivers. Home Health Care Services Quarterly, 26(4):57-78. Naylor MD, Knobel SR, Robinson KM, Hill-Millbourne VR, Bowles KH, Maislin G. (2007). Community-Based Care for High Risk Adults with Severe Disabilities. Home Health Care Management & Practice, 19(6):255-266. Naylor MD. (2007). Advancing the Science in the Measurement of Healthcare Quality Influenced by Nurses. Medical Care Research & Review, 64(2):144-169S. McCauley KM, Bixby MB, Naylor MD. (2006). Advanced Practice Nurse Strategies to Improve Outcomes and Reduce Cost in Elders with Heart Failure. Disease Management, 9(5):302-310. Naylor MD. (2006). Transitional Care: A Critical Dimension of the Home Healthcare Quality Agenda. Journal for Healthcare Quality, 28(1):48-54. Foust JB, Naylor MD, Boling PA, Cappuzzo KA. (2005). Opportunities for Improving Post-Hospital Home Medication Management among Older Adults. Home Health Care Services Quarterly, 24(1-2):101-122.

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Naylor MD, Stephens C, Bowles KH, Bixby MB. (2005). Cognitively impaired older adults: From hospital to home. A pilot study of these patients and their caregivers. American Journal of Nursing, 105(2):40-49. Naylor MD. (2004). Transitional Care Model for Older Adults: A Cost-Effective Model. LDI Issue Brief; 9(6):Apr/May. Naylor MD, Brooten DA, Campbell RL, Maislin GM, McCauley KM, Schwartz JS. (2004). Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized Clinical Trial. Journal of the American Geriatric Society, 52(5):675-684. Houldin AD, Naylor MD, Haller DG. (2004). Physician-nurse collaboration in research in the 21st century. Journal of Clinical Oncology, 22(5):774-776. Bowles KH, Holmes JH, Naylor MD, Liberatore M, Nydick R. (2003). Expert Consensus for Discharge Referral Decisions Using Online Delphi. Proceedings of the AMIA Annual Symposium, 106-109. Naylor MD. (2003). Nursing intervention research and quality of care: Influencing the future of healthcare. Nursing Research, 52(6):380-385. (invited paper) Bowles KH, Foust JB, Naylor MD. (2003). A multidisciplinary perspective of hospital discharge referral decision making. Applied Nursing Research, 16(3):134-143. Brooten D, Youngblut JM, Deatrick J, Naylor M, York R. (2002). Patient Problems, Advanced Practice Nurse (APN) Interventions, Time and Contacts Using APN Transitional Care Across 5 Patient Groups. Journal of Nursing Scholarship, 35(1):73-79. Brooten D, Naylor MD, York R, Brown LP, Munro BH, Hollingsworth AO, Cohen SM, Finkler S, Deatrick J, Youngblut JM. (2002). Lessons Learned from Testing the Quality Cost Model of Advanced Practice Nursing (APN) Transitional Care. Journal of Nursing Scholarship, 34(4):369-375. Note: Winner of the Sigma Theta Tau International's Best of the Journal of Nursing Scholarship Award in the Health Policy and Systems Category. Bowles K, Naylor M, Foust J. (2002). Patient Characteristics at Hospital Discharge and a Comparison of Home Care Referral Decisions. Journal of the American Geriatrics Society, 50:336-342. Bowles KH, Peng T, Naylor MD. (2001). Informatics application provides instant research in practice benefits. Proceedings of the AMIA Symposium, 66-70. Narsavage G and Naylor M. (2000). Factors Associated with Referrals of Elders with Cardiac and Pulmonary Disorders for Home Care Services Following Hospital Discharge. Journal of Gerontological Nursing, 26(5):14-20. Naylor M. (2000). A Decade of Transitional Care Research with Hospitalized Elders. Journal of Cardiovascular Nursing, 14(3):1-14.

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Naylor M, Bowles K, Brooten D. (2000). Patient Problems and Advanced Practice Nurse Interventions During Transitional Care. Public Health Nursing, 17(2):94-102. Naylor M and McCauley K. (1999). The Effects of a Discharge Planning and Home Follow-Up Intervention on Elders Hospitalized with Common Medical and Surgical Conditions. Journal of Cardiovascular Nursing, 14(1):44-54. Naylor M and Buhler-Wilkerson K. (1999). Creating Community-Based Care for the New Millennium. Nursing Outlook, 47(3):120-127. Naylor M, Brooten D, Campbell R, Jacobsen B, Mezey M, Pauly M, Schwartz J. (1999). Comprehensive Discharge Planning and Home Follow-Up of Hospitalized Elders: A Randomized Controlled Trial. Journal of the American Medical Association, 281(7):613-620. Mohr W and Naylor M. (1999). Breaking Through the Hegemony of Homogeneity: Revitalizing Curriculum and Students. Journal of Nursing Education, 38(1):28-32. Buhler-Wilkerson K, Naylor M, Holt S, Rinke L. (1998). An Alliance for Academic Home Care: Integrating Research, Education and Practice. Nursing Outlook, 46(2):77-80. Campbell R, Banner R, Konick-McMahon J, Naylor M. (1998). Discharge Planning and Home Follow-Up of the Elderly Patient with Heart Failure. Nursing Clinics of North America, 33(3):497-513. Mohr W and Naylor M. (1998). Creating Curriculum for the 21st Century. Nursing Outlook, 46(5):206-212. Happ MB, Naylor MD, Roe-Prior P. (1997). Factors Contributing to Rehospitalization of Elderly Patients with Heart Failure. Journal of Cardiovascular Nursing, 11(4):75-84. Bowles KH and Naylor MD. (1996). Nursing Intervention Classification Systems. Image: Journal of Nursing Scholarship, 28(4):303-308. Brooten D, Naylor M, Brown L, York R, Hollingsworth A, Cohen S, Roncoli M, Jacobsen B. (1996). Profile of Postdischarge Rehospitalizations and Acute Care Visits for 7 Patient Groups. Public Health Nursing, 13(2):128-134. Kresevic DM and Naylor M. (1995). Preventing Pressure Ulcers Through Use of Protocols in a Mentored Nursing Model. Geriatric Nursing, 16(5):225-229. Brooten D, Naylor M, York R, Brown L, Roncoli M, Hollingsworth A, Cohen S, Arnold L, Finkler S, Munro B, Jacobsen B. (1995). Effect of Nurse Specialist Transitional Care on Patient Outcomes and Cost: Results of 5 Randomized Trials. The American Journal of Managed Care, 1(1):45-51.

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Brooten D and Naylor M. (1995). Nurses’ Effect on Changing Patient Outcomes. IMAGE: Journal of Nursing Scholarship, 27(2):95-99. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. (1994). Comprehensive Discharge Planning for the Hospitalized Elderly: A Randomized Clinical Trial. Annals of Internal Medicine, 120(12):999-1006. Naylor M and Brooten D. (1993). Roles and Functions of Clinical Nurse Specialists: State of the Science. Image: Journal of Nursing Scholarship, 25(2):99-104. Naylor M, Brooten D, Brown L, Borucki L. (1991). Institutional Yield on Research: A Case Study. Nursing Outlook, 39(4):166-169. Naylor M and Chapman-Shaid E. (1991). Content Analysis of Pre- and Post-Discharge Topics Taught to Hospitalized Elderly by Gerontological Clinical Nurse Specialists. Clinical Nurse Specialist, 5(2):111-115. Naylor M, Munro B, Brooten D. (1991). Measuring the Effectiveness of Nursing Practice. Clinical Nurse Specialist, 5(4):210-214. Naylor M. (1990). Special Feature: An Example of a Research Grant Application Comprehensive Discharge Planning for the Elderly. Research in Nursing and Health, 13:327-347. Naylor M. (1990). Comprehensive Discharge Planning for Hospitalized Elderly: A Pilot Study. Nursing Research, 39(3):156-160. Infante MS, Forbes E, Houldin A, Naylor M. (1989). A Clinical Teaching Project: Examination of a Clinical Teaching Model. Journal of Professional Nursing, 5(3):132-139. Naylor M and Sherman M. (1988). A Description of the Effects of Current Initiatives to Attract Quality Undergraduate Nursing Students. Journal of Professional Nursing, 4(4):268-273. Brooten D, Naylor M, Hayman LL. (1982). Career guide: to change what needs changing…doesn’t take Wonder Woman. Nursing, 11(3):81-87. Brooten D, Hayman L, Naylor M. (1978). Leadership for Change. American Journal of Nursing, 78:1526-29.

Monographs

Naylor M. Nursing Education and the Shortage. American Nurses’ Association and the Association of Nurse Executives. Kansas City, Missouri. ANA/AONE, February 1990, 215.

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Naylor M. The Health Status and Health Care Needs of Older Americans. US, Senate Special Committee on Aging, Washington, D.C. U.S. Government Printing Office (Serial No. 99-L), November 1986, 1-37.

Books

Brooten D, Hayman L, Naylor M. (1988). Leadership for Change: An Action Guide for Nurses. (2nd Edition) Philadelphia: J.B. Lippincott Company. Masiak J, Naylor M, Hayman L. (1985). Fluids and Electrolytes Through The Life Cycle. Connecticut: Appleton-Century-Crofts, Inc.

Book Chapters

Vega A and Naylor MD. (2016, in press). Team Science: Challenges and Opportunities in the 21st Century. In P.A. Grady & A.S. Hinshaw (Eds.), Using Nursing Research to Shape Health Policy. New York: Springer. Naylor MD. (2011). Better Use of Healthcare Professionals. (pp. 536-542). In P.Y. Yong & L. Olsen (Eds.), The Healthcare Imperative: Lowering Costs and Improving Outcomes. Workshop Series Summary, Roundtable on Value & Science-Driven Health Care. Washington, DC: The National Academy Press. Naylor MD and Kurtzman ET. (2010). Transitional Care: Improving Health Outcomes and Decreasing Costs for At-Risk Chronically Ill Older Adults. (pp.201-213). In: A.S. Hinshaw & P.A. Grady (Eds.), Shaping health policy through nursing research. New York: Springer. Naylor MD and Van Cleave J. (2010). The Transitional Care Model for Older Adults. (pp. 459-465). In: A.I. Meleis (Ed.), Transitions Theory: Middle Range and Situation Specific Theories in Research and Practice. New York: Springer. Naylor M. (2003). Transitional Care of Older Adults (pp.127-147) In: P. Archbold, & B. Stewart (Eds.). Annual Review of Nursing Research, Vol. 20. New York: Springer. Naylor M. (2001). Research Vignette. Nursing Research: Impacting the Lives of the Frail Elderly. (pp.2-3). In G. LoBiondo-Wood & J. Haber (Eds.). Nursing Research: Methods, Critical Appraisal, and Utilization. (5th ed.). St. Louis: Mosby. Naylor M, Bowles K, Campbell R, McCauley K. (2001). Discharge planning: Design and implementation.(pp. 197-212). In T. T. Fulmer, M.D. Foreman, M. Walker, & K.S. Montgomery (Eds.). Critical Care Nursing of the Elderly. (2nd ed.). New York: Springer. McCauley KM and Naylor MD. (2001). Managing heart failure: Economic impact and outcomes. In D.K. Moser & B. Riegel (Eds.). Improving Outcomes in Heart Failure. Gaithersburg, MD: Aspen, 31-40.

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Bowles KH, Peng T, Qian R, Naylor M. (2001, Nov. 7). Informatics application provides instant research to practice benefits. American Medical Informatics Association 2001 Published Proceedings and CD ROM. Brooten D and Naylor MD. (1999). Transitional Environments that Optimize Outcomes. In A.S. Hinshaw, S. Feetham, J. Shaver (Eds.) Handbook of Clinical Nursing Research, Thousand Oaks, CA: Sage, 641-653. Naylor M and Roe-Prior P. (1999). Transitions Between Acute and Long Term Care. In P.R. Katz, M. Mezey and R. Kane (Eds.) Advances in Long Term Care-Volume IV. New York: Springer, 1-22. Brooten D and Naylor M. (1999). Transitional Care. In J.J. Fitzpatrick (Ed.), Encyclopedia of Nursing Research, New York: Springer, 567-569. Campbell R and Naylor M. (1998). Discharge Planning and Home Follow-Up of Elders. In Botrell, M., Abraham, I., Fulmer, T. & Mezey M. (Eds). Geriatric Nursing Protocols for Best Practice. Philadelphia: W.B. Saunders. Kresevic DM and Naylor M. (1998). Preventing Pressure Ulcers through Use of Protocols in a Mentored Nursing Model. In Bottrell, M., Abraham, I., Fulmer, T., Mezey, M. (Eds.), Geriatric Nursing Protocols for Best Practice. Philadelphia: W.B. Saunders. Naylor M. (1994). Nursing Practice. Illustrated Manual of Nursing Practice. (2nd Edition) Springhouse, PA; Springhouse Publishing Co. Naylor M, Campbell R, Foust J. (1993). Meeting the Discharge Needs of Hospitalized Elderly and Their Caregivers. In Funk, SG, Tornquist, E.M., Champagne M.T. & Wiese, R.A. (Eds.), Key Aspects of Caring for the Chronically Ill: Hospital and Home, New York: Springer Publishing Co., 142-150. Naylor M. (1992). The Implications of Discharge Planning for Hospitalized Elderly. In Fulmer T. & Walker, M. K. (Eds.), Critical Care Nursing of the Elderly. New York: Springer Publishing Co., 331-347. Naylor M. (1992). Recruitment of Students into Nursing. In McCloskey, J.C. & Grace, H.K. (Eds.) Current Issues in Nursing. (4th Edition) St. Louis: C.V. Mosby Co. Naylor M. (1991). Nursing Practice. In: Schull, P. (Ed.), Nursing 91: Illustrated Manual of Nursing Practice. Springhouse, PA: Springhouse Publishing Co. Naylor M. (1990). Recruitment of Students into Nursing. In: McCloskey, J.C. & Grace H.K. (Eds.), Current Issues in Nursing. (3rd Edition) St. Louis: C.V. Mosby Co.

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Reports

Frampton SB, Guastello S, Hoy L, Naylor MD, Sheridan S, Johnston-Fleece M. 2017. “Harnessing Evidence and Experience to Change Culture: A Guiding Framework for Patient and Family Engaged Care. Perspectives, National Academy of Medicine. Rowe JW, Berkman L, Fried L, Fulmer T, Jackson J, Naylor M, Novelli W, Olshansky J, Stone R. 2016. “Preparing for Better Health and Health Care for an Aging Population.” Vital Directions for Health and Health Care Series, National Academy of Medicine. Accountable Care Learning Collaborative. 2016. “Care Coordination.” A Call for Collaborative Action: Identifying Required Competencies for Success in Value-Based Care. Care Coordination Workgroup, www.accountablecareLC.org. IOM (Institute of Medicine). 2013. Delivering high-quality cancer care: Charting a new course for a system in crisis. Washington, DC: The National Academies Press. Josiah Macy Jr. Foundation. 2013. Transforming Patient Care: Aligning Interprofessional Education with Clinical Practice Redesign. Conference Recommendations. IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press. Naylor MD and Kurtzman ET. 2011. Aligning Our Efforts to Achieve Care Coordination. Care Coordination Convening Meeting. National Priorities Partnership, Convened by the National Quality Forum: Washington, DC.

Major Research and Professional Leadership Committees

2015 - Co-Chair, Care Culture and Decision-Making Innovation Collaborative, Leadership Consortium for Value & Science-Driven Health Care, National Academy of Medicine

2013 - 2014 Member, Betty Irene Moore Nursing Initiative Assessment Steering Committee, Gordon and Betty Moore Foundation

2012 - 2013 Member, Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population, Institute of Medicine

2012 - 2013 Co-Chair, Macy Conference on Interprofessional Education, Transforming Patient Care: Aligning IPE with Clinical Practice Redesign

2012 - 2014 Member, Patient Care Advisory Committee, Gordon and Betty Moore Foundation

2011 - Member, Professional Advisory Committee, UnitedHealth Care 2011 - Member, Chronic Care Initiative Steering Committee, Commonwealth of

Pennsylvania 2011 - Member, Care Coordination Policy Task Force, American Academy of

Nursing, Washington, DC

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2010 – 2012 Member, Learning Healthcare System in America Committee, Institute of Medicine, Washington, DC

2009 - 2011 Member, H2H National Quality Improvement Initiative, Executive Team and Advisory Committee

2009 - 2010 Member, Evidence Task Force, National Quality Forum 2009 – 2010 Co-Chair, IHI 11th Annual International Summit on Improving Patient

Care in the Office Practice and the Community 2007 – 2010 Member, Quality Alliance Steering Committee (QASC) 2007 - Member, Leadership Consortium for Value & Science-Driven Health

Care, National Academy of Medicine (formerly, Roundtable on Value & Science-Driven Health Care, Institute of Medicine)

2007 - 2011 Member, Governor’s Chronic Care Management, Reimbursement, and Cost Reduction Commission, Commonwealth of Pennsylvania

2006 - 2008 Member, Planning Advisory Committee Tracking NQF-Endorsed Consensus Standards for Nursing-Sensitive Care National Quality Forum, Washington, DC

2006 - 2007 Member, Chronic Care Workgroup, Department of Health & Human Services, Office of the National Coordinator for Health Information Technology, American Health Information Community, Washington DC

2005-2006 Member, Healthcare for Older Persons with Multiple Chronic Conditions: Establishing a Research Agenda, Department of Health & Human Services, Agency for Healthcare Research and Quality, Baltimore, MD

2005-2007 Member, Quality of Health Care Panel Commonwealth of Pennsylvania, Office of the Governor Office of Health Care Reform , Harrisburg, PA

2003-2004 Co-Chair, Nursing Care Performance Measures Steering Committee National Quality Forum, Washington, DC

2003-2004 Member, Health Advisory Committee Alberta Heritage Foundation for Medical Research Edmonton, Alberta, Canada

2001-2005 Member, National Advisory Council National Institute of Nursing Research, National Institutes of Health Bethesda, MD

1999-2003 Grant Reviewer, National Alzheimer’s Association, Washington, DC 1999 Consultant, “National Demonstration and Evaluation of Home Hospital”

The John A. Hartford Foundation, New York, NY 1998 Member, Research Committee. National PACE Association

San Francisco, CA 1995 Member, Review Team, National Institute of Nursing Research

Division of Intramural Research, Bethesda, MD 1994-1998 Standing Member, Scientific Review Committee, Agency for Health Care

Policy and Research, Bethesda, MD 1987 Member, Review Team National Fellowship Program

W. K. Kellogg Foundation, Battle Creek, MI

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Board Membership and Advisory Groups

Boards 2015-(2017) Member, National Advisory Council, Agency for Healthcare Research and

Quality 2011-(2017) Member, ABIM Foundation Board of Trustees 2011- Member, The Dorothy Rider Pool Health Care Trust 2010-2017 Member, Long-Term Quality Alliance Board of Directors 2010-2012 Chair, Long-Term Quality Alliance, Founding Board of Directors 2010- Trustee, Villanova University Board of Trustees 2010-2016 Member, Medicare Payment Advisory Commission (MedPAC) 2009-2015 Member, National Quality Forum Board of Directors 2009-2015 Member, Institute of Medicine Board on Healthcare Services 2008- Member, RAND Health Board of Advisors 2008-2009 Member, Nursing Quality and Safety Alliance 2005- Member, Health Quality Partners, Doylestown, PA 2002- President, Board of Directors, NewCourtland, Inc., Philadelphia, PA 1998-2009 Trustee, Waverly Heights, Chair, Health and Wellness Committee

Gladwyne, PA 1997- Trustee, NewCourtland, Inc., Member, Executive Committee 1997 Member, Advisory Group, Research Center, Department of Nursing

Oxford Brookes University, Oxford, England 1997- Trustee, Presbyterian Foundation, Member, Board Effectiveness

Committee, Philadelphia, PA 1994-1996 Trustee, Presbyterian Medical Center, Philadelphia, PA

Advisory Positions 2015- Member, External Advisory Committee, Health Care Systems Research

Network and Older American Independence Centers, AGING Initiative 2015-2016 Member, Nursing Home Task Force, Commonwealth of Pennsylvania

Department of Health 2014 - 2015 Member, RAND Technical Advisory Panel on Innovative Uses of Data

and Information Technology for Care Coordination 2012 - Member, Trajectories and Palliation Study (TAPS) Expert Panel, RAND 2012 - Member, Aetna Medicare Provider Collaboration Advisory Council 2012 - 2015 Member, VHA Center for Applied Healthcare Studies Advisory Group,

VHA, Inc., Irving, TX 2010 - 2012 Member, American Board of Internal Medicine, Practice Improvement

Module Oversight Committee 2010 - 2012 Member, Advisory Group, Preventing Avoidable Episodes (PAVE), The

Health Care Improvement Foundation, Philadelphia, PA 2010 - 2012 Member, Technical Advisory Panel, ASPE ARRA Comparative

Effectiveness Research Evaluation, Mathematica 2010 - Member, Technical Advisory Panel, Independence at Home, RTI

International

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2009 - 2011 Member, Executive Team, Hospital to Home (H2H): Excellence in Transitions Advisory Council, American College of Cardiology

2007 Member, Advisory Board for Improvements in Care Coordination for Older Adults, Society of Hospital Medicine

2004 Member, Steering Committee, Pennsylvania Governor's Conference for Women

2000 Member, National Advisory Group, Acute Care Demonstration Initiative, National Alzheimer’s Association, Washington, DC

1993-1997 Member, Advisory Group, NICHE Project funded by The John A. Hartford Foundation, New York University, New York, NY

1987 Member, Advisory Panel, PEW Memorial Trust Nursing Education Project, American Association of Colleges of Nursing and the National League for Nursing, New York

Testimony U.S. Senate Committee on Finance, 2009

U.S. House of Representatives Appropriations Committee on behalf of the American Association of Colleges of Nursing, 1999 U.S. House of Representatives Energy and Commerce Committee on behalf of the American Association of Colleges of Nursing, 1998 U.S. Senate Special Committee on Aging, 1998 Presidential Commission on HIV Epidemic, 1988 U.S. Senate Subcommittee on Veterans Affairs on behalf of the American Association of Colleges of Nursing, 1987

Editorial Positions

Guest Editor 2009 Health Affairs, special issue on Long-Term Supports and Services Editorial Board Membership 2002- The Journal of Cardiovascular Nursing 1998-1999 Nursing Outlook 1997-1999 Nursing Forum

Peer Reviewer Journal of the American Medical Association Annals of General Internal Medicine British Medical Journal Journal of Applied Gerontology Journal of the American Geriatrics Society Health Affairs New England Journal of Medicine Nursing Outlook

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Journal of Cardiovascular Nursing Western Journal of Nursing Research HSR: Health Services Research

Memberships in Professional and Scientific Societies

National Academy of Medicine (formerly, Institute of Medicine) American Academy of Nursing AcademyHealth American Geriatrics Society American Heart Association Council on Cardiovascular Nursing Council for the Advancement of Nursing Science American Nurses Association Pennsylvania Nurses Association Gerontological Society of America Sigma Theta Tau International Honor Society, Xi Chapter Heart Failure Society of America

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University of Pennsylvania Service Activities

University Member, Faculty Senate, Hearing Board (2012-2013) Member, Academic Planning and Budget Committee (2006-2009) Member, University Council Committee on International Programs (2004-2005) Member, Search Committee for University Provost (2004-2005) Member, Center for Technology Transfer, Advisory Committee (2001-2002) Member, Search Committee for Dean of the School of Nursing (2000-2001) Member, Council of Undergraduate Deans (1986-1998) Member, Provost's Planning Committee on Undergraduate Education (1997-1998) Senior Fellow and Member, Executive Committee, Leonard Davis Institute for Health

Economics (1986-Present) Member, Provost's Task Force on Study Abroad (1990-1998) Fellow, Center for the Study of Aging/Institute on Aging (1986-Present) Member, Primary Care Collaboration Joint Task Force with School of Medicine (1992) Member, Pappas Fellow Selection Committee (1994) Member, Search Committee, Vice Provost for University Life (1987-88) Member, Advisory Board, International Studies Program (1990-1997) Member, Pre-Freshman Program Planning Committee (1990-1998) Member, School of Medicine, Scholarship Selection Committee (1995) Member, Council of Undergraduate Medical Education (1995-1998) Member, VA Deans Committee, Alternate (1990-1996) Member, College of General Studies Internal Review Committee (1991) Member, Library Advisory Committee (1996-1998)

School of Nursing Chair, Undergraduate Curriculum Committee (1986-1998) Member, Academic Standards Committee (1992-1994) Member, Executive Committee (1986-1998) Member, Division Heads/Long Range Planning Committee (1986-1998) Undergraduate Admissions and Financial Aid, ex officio (1992-1998) Chair, LIFE Education (1998-2006) Chair, Hillman Advisory Committee (1997-2012) Member, Graduate Group (1986-Present) Member, Library/Instructional Technology Committee (1990-1998) Member, LIFE Leadership Committee (1998-2006) Chair, LIFE Education and Research Committee (1998-2006) Chair, Strategic Planning Committee (1999-2000) Member, Personnel Committee (2003-Present) Chair, Personnel Committee (2006-2007) Member, Penn/Beverly Task Force (2004-2005) Member, Academic Freedom Committee (2004-2007, 2009-2014) Member, Doctoral Admissions Committee (2004-Present)