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

Mae M Centeno; Kellie L Kahveci

doi:10.1016/j.ccell.2014.08.009

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.

Authors

Mae M Centeno¹, Kellie L Kahveci²

Affiliations

¹ 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.
² Baylor HouseCalls and Transitional Care Program, Health Texas Provider Network, 4004 Worth Street Suite 200, Dallas, TX 75246, USA.

PMID: 25438900
DOI: 10.1016/j.ccell.2014.08.009

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.

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