title: Transitional care interventions prevent hospital readmissions for adults with chronic illnesses.
abstract: Transitional care interventions aim to improve care transitions from hospital to home and to reduce hospital readmissions for chronically ill patients. The objective of our study was to examine if these interventions were associated with a reduction of readmission rates in the short (30 days or less), intermediate (31-180 days), and long terms (181-365 days). We systematically reviewed twenty-six randomized controlled trials conducted in a variety of countries whose results were published in the period January 1, 1980-May 29, 2013. Our analysis showed that transitional care was effective in reducing all-cause intermediate-term and long-term readmissions. Only high-intensity interventions seemed to be effective in reducing short-term readmissions. Our findings suggest that to reduce short-term readmissions, transitional care should consist of high-intensity interventions that include care coordination by a nurse, communication between the primary care provider and the hospital, and a home visit within three days after discharge.
authors.affiliation: Kim J. Verhaegh (k.j.verhaegh@amc.uva.nl) is a PhD student in the Departments of Internal Medicine and Geriatrics at the Amsterdam Medical Centre, in the Netherlands.
authors.forename: Kim J
authors.initials: KJ
authors.lastname: Verhaegh
authors.affiliation: Janet L. MacNeil-Vroomen is a PhD student in the Department of Internal Medicine and Geriatrics at the Amsterdam Medical Centre.
authors.forename: Janet L
authors.initials: JL
authors.lastname: MacNeil-Vroomen
authors.affiliation: Saeid Eslami is a senior researcher in the Department of Medical Informatics at the Amsterdam Medical Centre.
authors.forename: Saeid
authors.initials: S
authors.lastname: Eslami
authors.affiliation: Suzanne E. Geerlings is an internal medicine specialist in the Department of Internal Medicine at the Amsterdam Medical Centre.
authors.forename: Suzanne E
authors.initials: SE
authors.lastname: Geerlings
authors.affiliation: Sophia E. de Rooij is a professor in the Department of Internal Medicine and Geriatrics at the Amsterdam Medical Centre.
authors.forename: Sophia E
authors.initials: SE
authors.lastname: de Rooij
authors.affiliation: Bianca M. Buurman is a assistant professor in the Department of Internal Medicine and Geriatrics at the Amsterdam Medical Centre.
authors.forename: Bianca M
authors.initials: BM
authors.lastname: Buurman
mesh_terms: D002908:Chronic Disease; D003266:Continuity of Patient Care; D006699:Home Care Services; D006801:Humans; D010359:Patient Readmission; D058996:Quality Improvement; D016032:Randomized Controlled Trials as Topic
keywords: Elderly; Hospitals; Managed Care; Organization and Delivery of Care; Quality Of Care