Health care systems are increasingly focused on efforts to reduce hospital readmissions; a wide
variety of evidence exists on interventions to reduce readmissions, and national and local quality
improvement efforts focused on transitional care have also been developed.
Transitional care interventions can be resource intensive, however, and can include many
different components. For health systems that endeavor to improve the transitional care
experience for their patients, it is a challenge to define the specific nature of interventions they
should adopt, as well as which patient populations they should target.
This report broadly summarizes evidence examining the effects of transitional care interventions.
In particular, the report identifies key themes that have emerged across the transitional care
intervention literature that clarify which types of intervention are associated with reduced
readmissions and/or mortality, whether intervention effects differ depending on the setting in
which they are implemented, and whether effects differ across patient populations. Additionally,
we outline potential policy implications based on the themes emerging from the evidence as well
as our own clinical, research, and policy experience with transitional care within the Veterans
Health Administration (VHA).
Key Question 1: Which transitional care intervention characteristics are associated with
reductions in readmission rates?
Key Question 2:
Do the effects of transitional care interventions vary depending on the setting in
which they are implemented?
Key Question 3:
How does the choice of patient population targeted influence the effects of
transitional care interventions?