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ESP Report: Transitions of Care from Hospital to Home

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Transitions of Care from Hospital to
Home: An Overview of Systematic
Reviews and Recommendations for
Improving Transitional Care in the
Veterans Health Administration

Principal Investigator: Devan Kansagara, MD, MCR
Co-Investigators: Joseph C Chiovaro, MD; David Kagen, MD; Stephen Jencks, MD, MPH; Kerry Rhyne, MD; Maya O'Neil, PhD; Karli Kondo, PhD; Rose Relevo, MLIS, MS; Makalapua Motu'apuaka, BS; Michele Freeman, MPH; Honora Englander, MD

Evidence-based Synthesis Program (ESP) Center, Portland VA Medical Center, Portland, OR

Washington (DC): Department of Veterans Affairs; January 2015

Download PDF: Complete Report, Executive Summary, Report, Appendices


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 questions:

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?

See also

Kansagara D, Chiovaro J, Kagen D, et al. So many options, where do we start? An overview of the care transitions literature. Journal of Hospital Medicine. 2016;11(3)221-230.

A Review: Transitions of Care from Hospital to Home - Management eBrief

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