Evidence map›Paper›PMID 39582355›Full record

Trial reportJournal of advanced nursing2025

Implementing the MIRROR-TCM Randomised Control Trial During the COVID-19 Pandemic: A Mixed-Methods Evaluation.

Molly McHugh, Karen B Hirschman, Mark P Toles, Monica Ahrens, Brianna Morgan, Onome Osokpo, Elizabeth C Shaid, Kathleen McCauley, Alexandra L Hanlon, Mark V Pauly and 1 more

Registry-linked trialAbstract readRandomized Controlled Trial
In one paragraph

Trial report in Journal of advanced nursing, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. It is linked to trial NCT04212962 (Evaluation of the Multisite Replication of the Transitional Care Model), which is not on this map. Cited by 2 papers.

0numbers the graph read from it
0cells of the map it votes in
2citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

NCT04212962 naactive not recruitingnot on this map

Evaluation of the Multisite Replication of the Transitional Care Model

TypeinterventionalSponsorMathematica Policy Research, Inc.Ran2020 to 2026Enrolled962ConditionsCHF - Congestive Heart Failure, COPD, PneumoniaArmsTransitional care model (TCM), Usual care
3 · Its place in the literature

Who cites it

2 citing papers in PubMed.

  1. Article
  2. Implementation Fidelity of the Transitional Care Model: A Mixed Methods Study.Global implementation research and applications · 2026
    Article
4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

11 authors.

Molly McHughNewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.ORCID https://orcid.org/0000-0003-1418-1984
Karen B HirschmanNewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.
Mark P TolesUniversity of North Carolina at Chapel Hill School of Nursing, Chapel Hill, North Carolina, USA.
Monica AhrensDepartment of Statistics, Center for Biostatistics and Health Data Science, College of Science, Virginia Tech, Blacksburg, Virginia, USA.
Brianna MorganNew York University Grossman School of Medicine, New York, New York, USA.ORCID https://orcid.org/0000-0001-6717-0520
Onome OsokpoPopulation Health Nursing Science, University of Illinois Chicago, Chicago, Illinois, USA.ORCID https://orcid.org/0000-0002-6500-2491
Elizabeth C ShaidNewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.
Kathleen McCauleyNewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.
Alexandra L HanlonDepartment of Statistics, Center for Biostatistics and Health Data Science, College of Science, Virginia Tech, Blacksburg, Virginia, USA.
Mark V PaulyWharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Mary D NaylorNewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.

Funding

Individualized Care for At Risk Older AdultsT32NR009356 · NINR · UNIVERSITY OF PENNSYLVANIA · PI Lauren M Massimo, MARY D NAYLOR · 2007 to 2026
$7.8M
Arnold Ventures 19-02984Health Services Research and Development Service Award from the United States Department of Veterans Affairs SDR20-392Missouri Foundation for Health #20-0006-OF-20National Institute of Nursing Research, National Institutes of Health T32NR009356NINR NIH HHS T32 NR009356
6 · The paper itself

Abstract

aimTo evaluate the implementation of the Transitional Care Model (TCM), an evidence-based, advanced practice registered nurse-led multi-component intervention, as part of a randomised controlled trial during the first year of the COVID-19 pandemic.

designParallel convergent mixed-methods approach.

methodsData for this study were collected between June 2020 and February 2021. Data from 78 patients who received the intervention and 68 recorded meetings with system leaders and clinical teams were analysed using descriptive statistics, directed content analysis, and joint display.

resultsFidelity to delivery of elements of the TCM components was variable, with the Hospital-to-Home visit elements having the widest range (14.3%-100%) and Maintaining Relationships elements having the highest range (97.3%-98.6%). There were 27 identified challenges and 15 strategies for implementing the TCM with fidelity during the pandemic.

conclusionThe COVID-19 pandemic impacted all aspects of the delivery of the TCM across all sites. This historical event highlighted the need for services and support for patients and caregivers transitioning from the hospital to home. IMPLICATIONS FOR NURSING AND PATIENT CARE: Evidence-based solutions are needed to enhance healthcare delivery and patient outcomes. Findings will guide nurses in implementing proven transitional care interventions. IMPACT: Findings will inform the implementation and scaling of transitional care and other evidence-based interventions across diverse healthcare settings. REPORTING

methodGRAMMS reporting guidelines. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

trial registrationClinicalTrials.gov identifier: NCT04212962. https://www. CLINICALTRIALS: gov/study/NCT04212962?titles=NCT04212962&rank=1.

Indexed as

COVID-19Transitional CareAdultAgedAged, 80 and overFemaleHumansMaleMiddle AgedPandemicsSARS-CoV-2evidence‐based practiceimplementationnursingolder adultstransitional caretransitions

Identifiers

PMID39582355
PMCPMC12535348

What OpenQuestion holds

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LicenceCC BY-NC-ND
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Registered trials

Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.