The Importance of Transitional Care in Achieving Health Reform

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 hospitalized patients with complex chronic conditions—often the most vulnerable—transfer in a safe and timely manner from one level of care to another or from one type of care setting to another.

Researchers conducted a systematic review of the literature and summarized 21 randomized clinical trials of transitional care interventions targeting chronically ill adults. They identified nine interventions that demonstrated positive effects on measures related to hospital readmissions—a key focus of health reform. Most of the interventions led to reductions in readmissions through at least 30 days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, they recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

April Issue of Health Affairs Focuses on Patient Safety and Health Care Quality

  1. 1 The Ongoing Quality Improvement Journey
  2. 2 A Road Map for Improving the Performance of Performance Measures
  3. 3 The Trade-Off Among Quality, Quantity, and Cost
  4. 4 Global Trigger Tool' Shows that Adverse Events in Hospitals May be Ten Times Greater Than Previously Measured
  5. 5 Preventing Bloodstream Infections
  6. 6 Measuring the Performance of Individual Physicians by Collecting Data from Multiple Health Plans
  7. 7 Measuring Health Care Performance Now, Not Tomorrow
  8. 8 Despite Improved Quality of Care in the Veterans Affairs Health System, Racial Disparity Persists for Important Clinical Outcomes
  9. 9 The Importance of Transitional Care in Achieving Health Reform
  10. 10 An Early Status Report on the Beacon Communities' Plans for Transformation Via Health Information Technology
  11. 11 A Comparative Study of 11 Local Health Department Organizational Networks
  12. 12 Public Health Performance
  13. 13 A Self-Assessment Process for Accreditation Preparedness
  14. 14 Public Health Delivery Systems
  15. 15 Regionalization in Local Public Health Systems
  16. 16 Public Health Services and Systems Research
  17. 17 A Shot in the Rear, Not a Shot in the Dark
  18. 18 What Predicts Local Public Health Agency Performance Improvement?
  19. 19 Growth of a Scientific Community of Practice
  20. 20 Evolution of Coauthorship in Public Health Services and Systems Research
  21. 21 Resources that May Matter
  22. 22 Evidence Links Increases in Public Health Spending to Declines in Preventable Deaths
  23. 23 Public Health Financial Management Competencies
  24. 24 Decision Science
  25. 25 Public Health Financial Management Needs
  26. 26 Data-Driven Management Strategies in Public Health Collaboratives
  27. 27 Using Geographic Information Systems to Match Local Health Needs with Public Health Services and Programs
  28. 28 Public Health Systems and Services Research
  29. 29 Local Public Health Capacities to Address the Needs of Culturally and Linguistically Diverse Populations
  30. 30 A Needs Assessment for Data and Methods in Public Health Systems Research
  31. 31 Mapping the Multidisciplinary Field of Public Health Services and Systems Research

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