title: Transitional care nurses help prevent readmits.
mesh_terms: D015142:Baltimore; D003266:Continuity of Patient Care / Q000458:organization & administration*; D006801:Humans; D033183:Interdisciplinary Communication; D017146:Models, Organizational; D010351:Patient Discharge / Q000592:standards*; D010353:Patient Education as Topic / Q000379:methods / Q000592:standards*; D010359:Patient Readmission / Q000592:standards / Q000639:trends*