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.

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

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

Disparities in transitional care training for caregivers of older adults based on race or financial status demonstrate need for changes in discharge processes and strategies to address bias.

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.

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

Details how two health plans in California developed programs to transition dually eligible members from institutional settings back into their communities.

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

A novel approach to home visiting delivers cost reduction and better care