title: Components of Comprehensive and Effective Transitional Care.
abstract: Transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve health outcomes and reduce preventable hospital readmissions, yet little is known about the critical elements of effective TC and how they relate to patients' and caregivers' needs and experiences. To address this gap, the Patient-Centered Outcomes Research Institute (PCORI) funded a national study, Achieving patient-centered Care and optimized Health In care transitions by Evaluating the Value of Evidence (Project ACHIEVE). A primary aim of the study is the identification of TC components that yield desired patient and caregiver outcomes. Project ACHIEVE established a multistakeholder workgroup to recommend essential TC components for vulnerable Medicare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components and then analyzed how well the set aligned with real-world patients' and caregivers' experiences. Through this process, the workgroup identified eight TC components: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients' and caregivers' well-being, care continuity, and accountability. Although the degree of attention given to each component will vary based on the specific needs of patients and caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all Medicare beneficiaries.
authors.affiliation: School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Mary D
authors.initials: MD
authors.lastname: Naylor
authors.affiliation: School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Elizabeth C
authors.initials: EC
authors.lastname: Shaid
authors.affiliation: Center for Healthcare Delivery Research and Evaluation, Westat, Rockville, Maryland.
authors.forename: Deborah
authors.initials: D
authors.lastname: Carpenter
authors.affiliation: Division of Health Management, Telligen, Greenwood Village, Colorado.
authors.forename: Brianna
authors.initials: B
authors.lastname: Gass
authors.affiliation: Families and Health Care Project, United Hospital Fund, New York, New York.
authors.forename: Carol
authors.initials: C
authors.lastname: Levine
authors.affiliation: Center for Health Services Research, University of Kentucky, Lexington, Kentucky.
authors.forename: Jing
authors.initials: J
authors.lastname: Li
authors.affiliation: School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Ann
authors.initials: A
authors.lastname: Malley
authors.affiliation: School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Kathleen
authors.initials: K
authors.lastname: McCauley
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Huong Q
authors.initials: HQ
authors.lastname: Nguyen
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Heather
authors.initials: H
authors.lastname: Watson
authors.affiliation: Division of Health Management, Telligen, Greenwood Village, Colorado.
authors.forename: Jane
authors.initials: J
authors.lastname: Brock
authors.affiliation: Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California.
authors.forename: Brian
authors.initials: B
authors.lastname: Mittman
authors.affiliation: School of Medicine, Boston University, Boston Medical Center, Boston, Massachusetts.
authors.forename: Brian
authors.initials: B
authors.lastname: Jack
authors.affiliation: School of Medicine, Boston University, Boston Medical Center, Boston, Massachusetts.
authors.forename: Suzanne
authors.initials: S
authors.lastname: Mitchell
authors.affiliation: School of Medicine, Louisiana State University, Baton Rouge, Louisiana.
authors.forename: Becky
authors.initials: B
authors.lastname: Callicoatte
authors.affiliation: Caregiver Action Network, Washington, District of Columbia.
authors.forename: John
authors.initials: J
authors.lastname: Schall
authors.affiliation: Center for Health Services Research, University of Kentucky, Lexington, Kentucky.
authors.forename: Mark V
authors.initials: MV
authors.lastname: Williams
mesh_terms: D003266:Continuity of Patient Care / Q000458:organization & administration*; D006760:Hospitalization; D006801:Humans; D006278:Medicare; D063868:Patient Outcome Assessment; D010359:Patient Readmission; D018802:Patient-Centered Care / Q000379:methods* / Q000458:organization & administration; D000069341:Transitional Care / Q000639:trends*; D014481:United States
keywords: accountability; complexity management; continuity; education; engagement