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
Peer-Reviewed 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.
Posted to The Playbook on