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.
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Adults Under 65 with Disabilities
People with Advanced Illness
Frail Older Adults
People with Multiple Chronic Conditions
People with Behavioral Health and Social Needs
Key Questions Answered
- What is transitional care?
- What kinds of transitional care are most effective at reducing readmissions?
Level of Evidence
ModerateWhat does this mean?