Individualized Care for At Risk Older Adults

Assuring that older adults with complex care needs have access to high-quality health and supportive services in the home—and ensuring adequate support for their caregivers—represents a growing societal challenge. Addressing these priorities requires research-informed solutions, particularly those designed to overcome persistent barriers that limit the ability of many older adults to safely remain at home. The expansion of “hospital at home” programs has increased demand for science-based care models that respond to individual needs and preferences, reduce the impact of non-medical challenges on health outcomes, and strengthen caregiver support during major health events (e.g., new diagnoses) and care transitions (e.g., movement across care settings). The 12 core faculty leading the proposed renewal of the NINR-funded Individualized Care for At-Risk Older Adults—a T32 training program housed in the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing—are uniquely positioned to prepare four predoctoral and two postdoctoral nurse trainees annually to conduct interdisciplinary research addressing these urgent priorities. Guided by chronic illness conceptual frameworks and with a central focus on the care transition needs of older adults and their caregivers, trainees will be prepared to conceptualize, design, and conduct research that advances integrated care models tailored for individuals living at home. The training program equips trainees with a strong foundation in theory, research ethics, and advanced methodologies, supporting the development of rigorous and reproducible studies conducted within a team science framework. Trainees will employ innovative and emerging research approaches, contribute to knowledge synthesis, and promote effective dissemination and implementation with the goal of informing healthcare practice and policy—while also showcasing the critical role of nursing in care innovation. This proposed renewal draws from faculty expertise in aging, transitional care, ethics, and research methods. Led by two internationally recognized nurse scientists, the program continues to evolve in ways that deepen both the conceptual and practical knowledge needed to develop and test care models for older adults and their caregivers. Enhanced training in methods will include advanced data science, mixed-methods, and multi-level intervention strategies with strong translational relevance. Since 2007, this T32 program has supported 23 predoctoral and 24 postdoctoral fellows who have gone on to make significant contributions to the field. We anticipate that the next cohorts will continue this trajectory—advancing effective solutions that strengthen care transitions and improve the lives of older adults and those who care for them.