title: Transitional care models: preventing readmissions for high-risk patient populations.
abstract: Transition from hospital to home is a vulnerable period for older adults with multiple chronic conditions. A pilot of the Transitional Care Model at a community hospital reduced readmission rates for patients with heart failure by 48%. This article shares the experience of a large metropolitan health care system in expanding transitional care across facilities to decrease readmission rates.
authors.affiliation: Chronic Care Continuum, Institute of Chronic Disease and Care Redesign, Baylor Health Care System at Dallas, 8080 North Central Expressway, Dallas, TX 75206, USA. Electronic address: Mae.Centeno@baylorhealth.edu.
authors.forename: Mae M
authors.initials: MM
authors.lastname: Centeno
authors.affiliation: Baylor HouseCalls and Transitional Care Program, Health Texas Provider Network, 4004 Worth Street Suite 200, Dallas, TX 75246, USA.
authors.forename: Kellie L
authors.initials: KL
authors.lastname: Kahveci
mesh_terms: D000368:Aged; D002908:Chronic Disease; D003266:Continuity of Patient Care / Q000458:organization & administration*; D005853:Geriatrics; D006699:Home Care Services / Q000458:organization & administration; D006801:Humans; D009203:Myocardial Infarction / Q000451:nursing / Q000534:rehabilitation; D019982:Organizational Case Studies; D010359:Patient Readmission; D012307:Risk Factors; D015206:Southwestern United States
keywords: Elderly; Geriatric; Readmissions; Transitional care