So Many Options, Where Do We Start? An Overview of the Care Transitions Literature

This resource provides a systematic review of transitional care interventions that reported hospital readmission as an outcome.

• Transitional care is a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care.

• Ten reviews of mixed patient populations consistently showed that enhanced discharge planning and hospital-at-home interventions reduced readmissions.
• Among seven reviews in specific patient populations, transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations.
• In general, effective interventions addressed multiple aspects of the care transition, extended beyond hospital stay, and had the flexibility to accommodate individual patient needs.