A systemic review of transitional care interventions reporting hospital readmission

Care management programs should include processes for evaluating patient-reported outcomes.

Health Resilience Specialists work with the patients to meet their personal health needs

Much of the evidence comes from small studies, so further testing is needed.

Key opportunities include strengthening information technology connections across service providers.

Systematic review finds that medical respite programs reduce acute care utilization outcomes for people experiencing homelessness.

Primary care-based community health worker program reduced emergency department use among people recently released from prison.

A mobile crisis program reduced hospitalization rates among individuals experiencing behavioral health crises.