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.

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

Initiative successfully implemented several evidence-based and promising addiction care models across multiple medical settings, including an inpatient addiction consult team, a low-threshold bridge clinic, peer recovery coaches, and office-based addiction treatment nurses.

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

Explored innovative integrated health plan approaches to improve care transitions. Health plans featured in the webinar participate in Promoting Integrated Care for Dual Eligibles (PRIDE), a project to advance health plan strategies for providing high-quality care for dually eligible beneficiaries.

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

Lower inpatient admissions rates in a transitional care intervention.

An interdisciplinary, hospital-based addiction medicine consultation team improved substance use disorder treatment engagement after hospitalization.

The benefits of a transitional care program.

How home visits are used by ACOs to improve care, lower costs.

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

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