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.

Keywords: Elderly; Geriatric; Readmissions; Transitional care.