Transitional care models: preventing readmissions for high-risk patient populations

Crit Care Nurs Clin North Am. 2014 Dec;26(4):589-97. doi: 10.1016/j.ccell.2014.08.009. Epub 2014 Sep 16.


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.

Publication types

  • Review

MeSH terms

  • Aged
  • Chronic Disease
  • Continuity of Patient Care / organization & administration*
  • Geriatrics
  • Home Care Services / organization & administration
  • Humans
  • Myocardial Infarction / nursing
  • Myocardial Infarction / rehabilitation
  • Organizational Case Studies
  • Patient Readmission*
  • Risk Factors
  • Southwestern United States