Transitional care (TC) has received widespread attention from researchers, health system
leaders, clinicians, and policy makers as they attempt to improve health outcomes and …

Persons with continuous complex care needs frequently require care in multiple settings.
During transitions between settings, this population is particularly vulnerable to experiencing …

With its focus on holistic approaches to patient care, caregiver support, and delivery system
redesign, geriatrics has advanced our understanding of optimal care during transitions. This …

Transitions in care from hospital to primary care for older patients with chronic diseases (CD)
are complex and lead to increased mortality and service use. In response to these …

Elderly, chronically ill people experience frequent changes in health status that require
transitions among health care providers and settings. This issue brief describes two projects …

Older adults with multiple chronic conditions complicated by other risk factors, such as
deficits in activities of daily living or social barriers, experience multiple challenges in …

Under the Affordable Care Act of 2010, a variety of transitional care programs and services
have been established to improve quality and reduce costs. These programs help …

Analyzes the need to improve the quality of transitional care for persons with complex care
needs. Definition of transitional care; Disadvantages of poorly executed transitional care; …

Despite a growing body of evidence that adaptations of evidence-based interventions (EBI)
are ubiquitous, few studies have examined the nature and rationale for modifications to the …

The Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms:
Transforming Institutional Care (OPTIMISTIC) project aims to reduce avoidable …