Transitional Care: Focusing on Patient-Centered Outcomes and Simplicity

Two systematic reviews in this issue examine clinical trials or observational studies that evaluated transitional care interventions and highlight the variability and lack of standardization in the care provided in these studies.

Abstract

Editorials18 September 2012Transitional Care: Focusing on Patient-Centered Outcomes and SimplicitySusan T. Bray-Hall, MDSusan T. Bray-Hall, MDFrom University of Colorado School of Medicine, Denver, CO 80220.Author, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-157-6-201209180-00010 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Much can go wrong when a patient moves from one care setting to another. Such "transitions of care" may involve the movement of patients among health care locations, providers, or different levels of care within the same location as health conditions and care needs change (1). Most research on transitions of care has focused on hospital discharge to another setting, such as home or a subacute rehabilitation center. The American Geriatrics Society defines transitional care as "a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of ...References1. National Transitions of Care Coalition. Transitions of Care Measures. Washington, DC: National Transitions of Care Coalition; 2008. Accessed at www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf on 12 August 2012. Google Scholar2. Coleman EA, Boult C; American Geriatrics Society Health Care Systems Committee. Improving the quality of transitional care for persons with complex care needs. J Am Geriatr Soc. 2003;51:556-7. [PMID: 12657079] CrossrefMedlineGoogle Scholar3. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Pr; 1999. Google Scholar4. Berenson RA, Paulus RA, Kalman NS. Medicare's readmissions-reduction program—a positive alternative. 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Prvu Bettger J, Alexander KP, Dolor RJ, Olson DM, Kendrick AS, Wing L, et al. Transitional care after hospitalization for acute stroke or myocardial infarction. A systematic review. Ann Intern Med. 2012;157:407-16. LinkGoogle Scholar10. Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C, et al. Improving patient handovers from hospital to primary care. A systematic review. Ann Intern Med. 2012;157:417-28. LinkGoogle Scholar11. Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat 119. Accessed at www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf on 2 August 2012. Google Scholar Author, Article, and Disclosure InformationAffiliations: From University of Colorado School of Medicine, Denver, CO 80220.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1935.Corresponding Author: Susan T. Bray-Hall, MD, University of Colorado School of Medicine, 1055 Clermont Street, #111-D, Denver, CO 80220; e-mail, [email protected]. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoTransitional Care After Hospitalization for Acute Stroke or Myocardial Infarction Janet Prvu Bettger , Karen P. Alexander , Rowena J. Dolor , DaiWai M. Olson , Amy S. Kendrick , Liz Wing , Remy R. Coeytaux , Carmelo Graffagnino , and Pamela W. Duncan Improving Patient Handovers From Hospital to Primary Care Gijs Hesselink , Lisette Schoonhoven , Paul Barach , Anouk Spijker , Petra Gademan , Cor Kalkman , Janine Liefers , Myrra Vernooij-Dassen , and Hub Wollersheim Metrics Cited ByPatient-Centered Approaches to Transitional Care Research and ImplementationStudy protocol: A cross‐sectional study on instrumental support for transitional care among older adults with chronic diseasesThe effectivity role of community mental health worker for rehabilitation of mental health illness: A systematic reviewRecommendations for reducing harm and improving quality of care for older people in residential respite careTransitional care: Concept analysis using Rodgers' evolutionary approachEffect of Intensive Interdisciplinary Transitional Care for High-Need, High-Cost Patients on Quality, Outcomes, and Costs: a Quasi-Experimental StudyConsensus development of components of continuity of care for stroke patients: a Delphi methodology"I Feel Worn Out, as if I Neglected Myself": Older Patients' Perspectives on Post-hospital Symptoms After Acute HospitalizationImpact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence ReviewNephrologists' Perspectives on Defining and Applying Patient-Centered Outcomes in HemodialysisIntegrated Health Care Barcelona Esquerra (Ais-Be): A Global View of Organisational Development, Re-Engineering of Processes and Improvement of the Information Systems. The Role of the Tertiary University Hospital in the TransformationStructure and processes of interdisciplinary geriatric consultation teams in acute care hospitals: A scoping reviewIncreased Mortality Rates During Resident Handoff Periods and the Effect of ACGME Duty Hour RegulationsHeadlines from the NLN: NINR/NLN Co-Sponsor 2015 National Nursing Research Roundtable: The Nexus of Practice, Research, and Education for the Health of the NationThe use of an automated notification system to identify and address early readmissions by a university hospitalist servicePending Studies at Hospital Discharge: A Pre-post Analysis of an Electronic Medical Record Tool to Improve Communication at Hospital DischargeVisualizing collaborative electronic health record usage for hospitalized patients with heart failureResearch in hospital discharge procedures addresses gaps in care continuity in the community, but leaves gaping holes for people with dementia: A review of the literatureTransitional Care Interventions Prevent Hospital Readmissions For Adults With Chronic IllnessesHospital-Initiated Transitional Care Interventions as a Patient Safety Strategy A Systematic ReviewStephanie Rennke, MD, Oanh K. Nguyen, MD, Marwa H. Shoeb, MD, Yimdriuska Magan, BS, Robert M. Wachter, MD, and Sumant R. Ranji, MD 18 September 2012Volume 157, Issue 6Page: 448-449KeywordsClinical trialsHealth careHealth care providersHospitalizationsMedicareMyocardial infarctionPatientsPopulation statisticsStrokeSystematic reviews ePublished: 18 September 2012 Issue Published: 18 September 2012 CopyrightCopyright © 2012 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...