title: The journey across the health care (dis)continuum for vulnerable patients: policies, pitfalls, and possibilities.
authors.affiliation: Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8025, USA.
authors.forename: Grace
authors.initials: G
authors.lastname: Jenq
authors.forename: Mary E
authors.initials: ME
authors.lastname: Tinetti
mesh_terms: D000359:Aftercare / Q000458:organization & administration*; D000368:Aged; D002908:Chronic Disease; D003266:Continuity of Patient Care; D019033:Delivery of Health Care, Integrated / Q000191:economics; D004636:Emergency Service, Hospital / Q000458:organization & administration; D006620:Hip Fractures / Q000534:rehabilitation / Q000628:therapy; D006760:Hospitalization; D006801:Humans; D007297:Inpatients; D010359:Patient Readmission; D012866:Skilled Nursing Facilities; D014481:United States; D035862:Vulnerable Populations