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

@article{Kamermayer2017TheEO,
  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},
  year={2017},
  volume={36},
  pages={311–316}
}
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… 
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19 Citations
Highly Influential Citations
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Background Citations
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Methods Citations
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Results Citations
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19 Citations

Implementation of a pharmacist-led transitions of care program in an indigent care clinic: A randomized controlled trial.

Decreasing Readmissions in Medically Complex Children

TLDR
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)

TLDR
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

TLDR
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

TLDR
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

TLDR
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

TLDR
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

TLDR
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

TLDR
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.

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