As the cost of care rises and fragmentation of health care increases, care transitions have
become critical parts of the health care system. Physicians and other inpatient providers …

Objective: Nearly one in five Medicare patients is readmitted to a hospital within 30 days of
discharge. Most of these admissions are preventable, coming at a cost both to the patient's …

Background The impact of multidisciplinary interventions to support patients moving from
hospital to home have generally demonstrated a benefit. However, the role of community …

Reducing hospital readmissions is a national healthcare priority. Most of the interventions to
reduce hospital readmission have been concentrated in the inpatient setting. However, there …

Background: Evidence shows that suboptimum handovers at hospital discharge lead to
increased rehospitalizations and decreased quality of health care. Purpose: To …

Poorly executed transitions in care from hospital to home are associated with increased
vulnerability to adverse medication events and hospital readmissions, and also excess …

ABSTRACT BACKGROUND Patients are vulnerable to poor quality, fragmented care as they
transition from hospital to home. Few studies examine the discharge process from the …

Transitions of care—when patients move from one health care facility to another or back
home—that are poorly executed result in adverse effects for patients. Fortunately, programs …

The coordination of care as patients move from one health care setting to another is crucial
to treatment, but breakdowns in the process lead to poor transitions, fragmented care …

BACKGROUND Health systems are faced with a large array of transitional care interventions
and patient populations to whom such activities might apply. PURPOSE To summarize the …