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