So Many Options, Where Do We Start? An Overview of the Care Transitions Literature

Paper
Key Questions Answered
  • What is transitional care?
  • What kinds of transitional care are most effective at reducing readmissions?
Key Themes and Takeaways

This resource provides a systematic review of transitional care interventions that reported hospital readmission as an outcome.

  • Transitional care is a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care.
  • Ten reviews of mixed patient populations consistently showed that enhanced discharge planning and hospital-at-home interventions reduced readmissions.
  • Among seven reviews in specific patient populations, transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations.
  • In general, effective interventions addressed multiple aspects of the care transition, extended beyond hospital stay, and had the flexibility to accommodate individual patient needs.
Authors
Devan Kansagara
Joseph C Chiovaro
David Kagen
Stephen Jencks
Kerry Rhyne
Maya O’Neil
Karli Kondo
Rose Relevo
Makalapua Motu’apuaka
Michele Freeman
Honora Englander
Population Addressed
Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Level of Evidence
Moderate Evidence
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