Transitional Care Can Reduce Hospital Readmissions
The American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine have worked together to develop consensus standards for transitional care. Practice standards have been developed based on this framework of guiding principles. Both the National Transitions of Care Coalition and the Institute for Healthcare Improvement's State Action on Avoidable Rehospitalizations specify standards of care and provide transition guides in these consensus standards. For a summary of all key recommendations from leading transitional care organizations, see Transitional care principles.) See box .
Other recommendations for improving care transitions have been developed by the National Transitions of Care Coalition (www.ntocc.org), Care Transitions Program (www.caretransitions.org), and Institute for Healthcare Improvement's State Action on Avoidable Hospitalizations program (www.ihi.org/offerings/Initiatives/STAAR/Pages/default.aspx). Using standardized forms aids implementation of these recommendations. (See the box .)
In a 2014 meta-analysis of 26 randomized controlled trials involving 7,932 subjects, one research group found 30-day readmissions were reduced only by high-intensity transitional care programs that included most of the activities listed in Transitional care principles. They found that a home visit within 3 days of hospital discharge, care coordination by an APRN or RN, and communication between the hospital team and primary care provider within 1 week of discharge were essential to transitional care programs that reduced 30-day readmissions.
Guidelines and Key Strategies for Transitional Care
The American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society of Academic Emergency Medicine have worked together to develop consensus standards for transitional care. Practice standards have been developed based on this framework of guiding principles. Both the National Transitions of Care Coalition and the Institute for Healthcare Improvement's State Action on Avoidable Rehospitalizations specify standards of care and provide transition guides in these consensus standards. For a summary of all key recommendations from leading transitional care organizations, see Transitional care principles.) See box .
Other recommendations for improving care transitions have been developed by the National Transitions of Care Coalition (www.ntocc.org), Care Transitions Program (www.caretransitions.org), and Institute for Healthcare Improvement's State Action on Avoidable Hospitalizations program (www.ihi.org/offerings/Initiatives/STAAR/Pages/default.aspx). Using standardized forms aids implementation of these recommendations. (See the box .)
In a 2014 meta-analysis of 26 randomized controlled trials involving 7,932 subjects, one research group found 30-day readmissions were reduced only by high-intensity transitional care programs that included most of the activities listed in Transitional care principles. They found that a home visit within 3 days of hospital discharge, care coordination by an APRN or RN, and communication between the hospital team and primary care provider within 1 week of discharge were essential to transitional care programs that reduced 30-day readmissions.
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