title: Transitions in care.
authors.forename: Kismet
authors.initials: K
authors.lastname: Rasmusson
mesh_terms: D015897:Comorbidity; D003266:Continuity of Patient Care; D019468:Disease Management; D007722:Health Knowledge, Attitudes, Practice; D006333:Heart Failure / Q000453:epidemiology / Q000628:therapy*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D010353:Patient Education as Topic; D010359:Patient Readmission / Q000706:statistics & numerical data