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

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
Journal Article
March 2016

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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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
Key Questions Answered
  • What is transitional care?
  • What kinds of transitional care are most effective at reducing readmissions?
Level of Evidence
What does this mean?