Nurse assessments of discharge readiness for older patients with multiple chronic conditions can help identify patients at high risk for hospital readmission.

Randomized controlled trial of a person-centered housing intervention for older adults shows improved health outcomes for formerly homeless adults living in permanent supportive housing.

Louisiana improved Medicaid enrollment and health care access for people reentering communities from state prisons.

A "virtual-first" transitional care program with an interdisciplinary care team can support reduced readmissions.

Resources to help organizations develop and improve medical respite programs for people experiencing homelessness.

A street medicine program increased post-hospitalization follow-up care for unsheltered individuals experiencing homelessness in Los Angeles.

A medical respite program for people experiencing homelessness shows evidence of reduced hospital readmissions and emergency department revisits.

An interdisciplinary team approach can improve care coordination and reduce length of hospital stays for older adults with complex health and social needs.

Longer participation in a patient-centered medical home is associated with better mental health care for people enrolled in Medicaid with major depressive disorder and multiple chronic conditions.

Home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.

Patients with dementia are more likely to be discharged to hospice from hospitals that offer palliative care programs.

A complex care transitions pilot designed through a stakeholder-driven process led to decreased hospital utilization and costs.

Lower inpatient admissions rates in a transitional care intervention.

The benefits of a transitional care program.

The importance of timely primary care follow-up.

Including caregivers in the discharge planning process reduces the risk of hospital readmission for older adults.

Home-based primary care program reduced hospitalizations for older adults with diabetes, especially those with higher levels of medical complexity.

The Care Transitions Intervention was co-designed with patients and evaluated using randomized trials.

A systemic review of transitional care interventions reporting hospital readmission