The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review

  title={The Effectiveness of Transitions-of-Care Interventions in Reducing Hospital Readmissions and Mortality: A Systematic Review},
  author={Angela K Kamermayer and Angela Renee Leasure and Lisa Anderson},
  journal={Dimensions of Critical Care Nursing},
Background: The Affordable Care Act of 2010 set forth payment models that provided $10 billion to incent the health care system in developing innovative programs that target reform, including transitional care to reduce preventable readmissions. While transitional care programs exist, US hospitals remain challenged, with 1 in 5 readmissions within 30 days. Objective: This systematic review examined the effectiveness of select evidence-based transitions-of-care interventions on reducing 30-day… 

Decreasing Readmissions in Medically Complex Children

The results of the project proved that implementing consistent discharge standards in medically complex children helped guide medical staff, improved patient outcomes, saved costs to the organization, and reduced 30-day all-cause hospital readmissions.

Impact of a Follow-up Telephone Call Program on 30-Day Readmissions (FUTR-30)

There is no evidence of an impact on 30-day readmissions or mortality due to the postdischarge telephone call program in patients discharged home from a hospital general medicine service or usual care discharge.

Opening Pandora’s Box

There is a need for patient-centered outcome measures (PCOMs) to be developed for transitional care settings to ensure that outcomes are both meaningful to patients and relevant to the particular care transition.

Reconceptualizing Care Transitions Research From the Patient Perspective

Improvement of transitional care remains a complex endeavor requiring research that employs nuanced modeling, employment of novel design and methodological approaches, attention to social context, and most importantly, measurement of and attention to the perspectives of the multiple stakeholders engaged in transitional care.

Discharge interventions from inpatient child and adolescent mental health care: a scoping review

A scoping review of literature on discharge interventions from inpatient CAMHS found that intervention elements included aspects of risk assessment, individualized care, discharge preparation, community linkage, psychoeducation, and follow-up support.

Reducing Hospital Readmission Rates via NP- Initiated Post Discharge Telephone Calls in Dialysis Dependent End Stage Renal Disease Patients

Purpose/Aim: To determine whether a nurse practitioner-initiated phone call, in addition to the standard transition-of-care (TOC) protocol, will reduce 30-day hospital readmissions by 50% in patients

Effect of clinical pharmacist encounters in the transitional care clinic on 30-day re-admissions: A retrospective study

It was found that each added co-morbidity significantly increased the patients' 30-day re-admission rate by 26% and the overall rates were not statistically different among the two groups.

Post-Discharge Transitional Care Program and Patient Compliance With Follow-Up Activities

Making the first phone call to patients, while crucial, may not be sufficient for effective care transition; making two to three phone calls seems to be more optimal, while further calls may have limited value.

My Bridge (Mi Puente), a care transitions intervention for Hispanics/Latinos with multimorbidity and behavioral health concerns: protocol for a randomized controlled trial

The protocol for a randomized controlled trial that will compare Mi Puente (My Bridge), a cost-efficient care transitions intervention conducted by a specially trained Behavioral Health Nurse and Volunteer Community Mentor team, to usual care or best-practice discharge approaches, in reducing hospital utilization and improving patient reported outcomes in Latinos with multiple cardiometabolic conditions and behavioral health concerns is reported.



The care span: The importance of transitional care in achieving health reform.

A systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform.

Evaluation of a Team-Based, Transition-of-Care Management Service on 30-Day Readmission Rates

Development of a team-based intervention was associated with a significant reduction in hospital readmissions, and this method could be implemented in other primary care offices withteam-based care.

The care transitions intervention: results of a randomized controlled trial.

Coaching chronically ill older patients and their caregivers to ensure that their needs are met during care transitions may reduce the rates of subsequent rehospitalization.

Implementation of the Re-Engineered Discharge (RED) Toolkit to Decrease All-Cause Readmission Rates at a Rural Community Hospital

Monthly readmission rates and patient/family involvement in the discharge process were examined for 336 patients discharged from a dedicated 30-bed medical-surgical unit in a rural community hospital over a 4-month period and the patient and family perception of their discharge process was positive.

Do Collaborative Case Management Models Decrease Hospital Readmission Rates Among High-Risk Patients?

Examination of the relationship of a collaborative case management model on hospital readmission rates among patients aged 65 years and older indicates that group characteristics did not distinguish who would get readmitted on the basis of independent variables measured.

Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.

Although patients who received the intervention were more likely to communicate and follow up with their physicians, the absence of impact on readmission suggests that more intensive efforts may be indicated to affect this outcome.

Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up.

Many patients discharged from this large urban academic hospital lacked timely outpatient PCP follow-up resulting in higher rates of readmission and a non-significant trend toward longer hospital LOS.

Effect of hospital follow-up appointment on clinical event outcomes and mortality.

Improved discharge processes, including arrangement of hospital follow-up appointments, do not appear to improve readmission rates or survival in general medicine patients, and national efforts to ensure follow- up for all patients after hospital dismissal may not be beneficial or cost-effective.

Financial Implications of Sepsis Prevention, Early Identification, and Treatment: A Population Health Perspective

  • J. Angelelli
  • Medicine, Political Science
    Critical care nursing quarterly
  • 2016
The financial costs of sepsis in the United States are reviewed, examining the evidence for its economic impact across both hospitals and nursing homes and highlighting the challenges and opportunities for interorganizational collaborative strategies in value-based models of care delivery.

The relationship between hospital admission rates and rehospitalizations.

A substantial association between regional rates of rehospitalization and overall admission rates is found and programs directed at shared savings from lower utilization of hospital services might be more successful in reducing readmissions than programs initiated to date.