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… Expand
View on Wolters Kluwer
ncbi.nlm.nih.gov
18 Citations
Highly Influential Citations
2
Background Citations
4
Methods Citations
1
Results Citations
1

18 Citations

Citation Type

Citation Type

Implementation of a pharmacist-led transitions of care program in an indigent care clinic: A randomized controlled trial.
TLDR
The intervention was successfully implemented in the clinic and showed promising results by reducing readmission rates, but patient-level barriers to follow-ups included transportation, accessibility, financial burdens, inconsistent telephone communication, and a lack of knowledge about the importance of follow-up. Expand
Decreasing Readmissions in Medically Complex Children
Practice Problem: There was a report of an existing practice problem of increased 30-day readmission rates in medically complex children at an outpatient clinic within an extensive hospital system.… Expand
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. Expand
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. Expand
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. Expand
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. Expand
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… Expand
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. Expand
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. Expand
Patient-Centered Approaches to Transitional Care Research and Implementation
TLDR
The papers in this Special Issue articulate challenges, lessons learned, and new directions for measurement, stakeholder engagement, implementation, and methodological and design approaches that reflect the complexity of transitional care comparative effectiveness research and seek to move the field toward a more holistic understanding of transitionalCare. Expand
...
1
2
...

References

SHOWING 1-10 OF 20 REFERENCES
The care span: The importance of transitional care in achieving health reform.
TLDR
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. Expand
Evaluation of a Team-Based, Transition-of-Care Management Service on 30-Day Readmission Rates
TLDR
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. Expand
The care transitions intervention: results of a randomized controlled trial.
TLDR
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. Expand
Implementation of the Re-Engineered Discharge (RED) Toolkit to Decrease All-Cause Readmission Rates at a Rural Community Hospital
TLDR
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. Expand
Do Collaborative Case Management Models Decrease Hospital Readmission Rates Among High-Risk Patients?
TLDR
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. Expand
Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.
TLDR
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. Expand
Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up.
TLDR
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. Expand
Effect of hospital follow-up appointment on clinical event outcomes and mortality.
TLDR
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. Expand
Financial Implications of Sepsis Prevention, Early Identification, and Treatment: A Population Health Perspective
TLDR
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. Expand
The relationship between hospital admission rates and rehospitalizations.
TLDR
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. Expand
...
1
2
...