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Posted: April 14th, 2023

Improving Care Transitions from Hospital to Home

Improving Care Transitions from Hospital to Home

Care transitions are the movements of patients between different health care settings, such as hospitals, nursing homes, home health agencies, and primary care providers. Care transitions are critical moments in the health care journey of patients, especially those with chronic conditions or complex needs. Poorly coordinated care transitions can lead to adverse events, medication errors, readmissions, and increased costs (Coleman and Boult 2003).

One of the most challenging care transitions is from hospital to home. Patients who are discharged from the hospital often face multiple challenges, such as managing new or changed medications, following up with outpatient providers, adhering to self-care instructions, and coping with physical and emotional stress. These challenges can be exacerbated by factors such as low health literacy, social isolation, lack of caregiver support, and inadequate communication between health care providers (Naylor et al. 2011).

To improve care transitions from hospital to home, several interventions have been developed and tested in various settings and populations. Some of the common elements of these interventions are:

– Providing patient-centered education and coaching on the discharge plan, medication management, warning signs, and follow-up care.
– Ensuring timely and accurate handoff of information between hospital and community-based providers.
– Arranging post-discharge follow-up visits or phone calls with primary care providers or transitional care nurses.
– Offering home visits or telehealth services to monitor patient status and provide additional support.
– Engaging patients and caregivers in shared decision making and goal setting.

One of the most widely studied interventions for improving care transitions from hospital to home is the Transitional Care Model (TCM), developed by Dr. Mary Naylor and colleagues at the University of Pennsylvania. The TCM is a nurse-led, evidence-based intervention that provides comprehensive in-hospital planning and home follow-up for chronically ill older adults. The TCM has been shown to reduce readmissions, improve quality of life, and lower costs for patients with heart failure, chronic obstructive pulmonary disease, diabetes, and other conditions (Naylor et al. 2014).

Another promising intervention for improving care transitions from hospital to home is Project RED (Re-Engineered Discharge), developed by Dr. Brian Jack and colleagues at Boston University. Project RED is a multifaceted intervention that involves a specially trained nurse discharge advocate who educates patients about their diagnosis, medications, follow-up appointments, and self-care; a pharmacist who calls patients after discharge to review medications and address any problems; and an electronic discharge summary that is sent to the primary care provider within 24 hours of discharge. Project RED has been shown to reduce readmissions, improve patient satisfaction, and save costs for patients with various diagnoses (Jack et al. 2009).

Improving care transitions from hospital to home is a key strategy for enhancing patient safety, quality of care, and health outcomes. By implementing evidence-based interventions that address the needs and preferences of patients and caregivers, health care organizations can reduce avoidable readmissions, improve patient satisfaction, and lower costs.


Coleman EA, Boult C. Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society 2003;51(4):556-557.

Jack BW, Chetty VK, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Annals of Internal Medicine 2009;150(3):178-187.

Naylor MD, Aiken LH, Kurtzman ET et al. The importance of transitional care in achieving health reform. Health Affairs 2011;30(4):746-754.

Naylor MD, Shaid EC, Carpenter D et al. Components of comprehensive and effective transitional care. Journal of the American Geriatrics Society 2017;65(6):1119-1125.

Naylor MD, Hirschman KB, Hanlon AL et al. Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults. Journal of Comparative Effectiveness Research 2014;3(3):245-257.


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