Systematic review: predictors of successful transition to community-based care for adults with chronic care needs

Care Manag J. 2008;9(4):154-65. doi: 10.1891/1521-0987.9.4.154.


Difficult transition from acute hospital back to the community can be challenging. Problems encountered during this process can lead to unplanned readmission and emergency department visits. It is important for care managers to be able to identify patients susceptible to difficult transition and to understand strategies to reduce risk of unplanned hospital readmission. This qualitative systematic review of 10 studies of discharge interventions and patient characteristics finds little evidence that enhanced discharge support is related to improved physical status at home, but there is mixed support for its role in preventing or delaying hospital readmissions in certain discharge diagnoses, specifically heart failure and stroke. Additionally, those with adequate social support and confidence in their self-care ability tend to experience fewer readmissions than do those living alone and those who perceive themselves as not ready to return home.

Publication types

  • Comparative Study
  • Review
  • Systematic Review

MeSH terms

  • Adaptation, Psychological
  • Adult
  • Aged
  • Chronic Disease
  • Data Interpretation, Statistical
  • Female
  • Home Care Services*
  • Home Care Services, Hospital-Based*
  • Humans
  • Male
  • Middle Aged
  • Patient Discharge
  • Prospective Studies
  • Quality of Life
  • Randomized Controlled Trials as Topic
  • Retrospective Studies
  • Surveys and Questionnaires
  • Time Factors