Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. 2014

Kim J Verhaegh, and Janet L MacNeil-Vroomen, and Saeid Eslami, and Suzanne E Geerlings, and Sophia E de Rooij, and Bianca M Buurman
Kim J. Verhaegh (k.j.verhaegh@amc.uva.nl) is a PhD student in the Departments of Internal Medicine and Geriatrics at the Amsterdam Medical Centre, in the Netherlands.

Transitional care interventions aim to improve care transitions from hospital to home and to reduce hospital readmissions for chronically ill patients. The objective of our study was to examine if these interventions were associated with a reduction of readmission rates in the short (30 days or less), intermediate (31-180 days), and long terms (181-365 days). We systematically reviewed twenty-six randomized controlled trials conducted in a variety of countries whose results were published in the period January 1, 1980-May 29, 2013. Our analysis showed that transitional care was effective in reducing all-cause intermediate-term and long-term readmissions. Only high-intensity interventions seemed to be effective in reducing short-term readmissions. Our findings suggest that to reduce short-term readmissions, transitional care should consist of high-intensity interventions that include care coordination by a nurse, communication between the primary care provider and the hospital, and a home visit within three days after discharge.

UI MeSH Term Description Entries
D010359 Patient Readmission Subsequent admissions of a patient to a hospital or other health care institution for treatment. Hospital Readmission,Rehospitalization,Unplanned Hospital Readmissions,Unplanned Readmission,30 Day Readmission,Hospital Readmissions,Readmission, Hospital,Readmissions, Hospital,Thirty Day Readmission,30 Day Readmissions,Hospital Readmission, Unplanned,Hospital Readmissions, Unplanned,Readmission, Patient,Readmission, Thirty Day,Readmission, Unplanned,Rehospitalizations,Thirty Day Readmissions,Unplanned Hospital Readmission,Unplanned Readmissions
D002908 Chronic Disease Diseases which have one or more of the following characteristics: they are permanent, leave residual disability, are caused by nonreversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation, or care (Dictionary of Health Services Management, 2d ed). For epidemiological studies chronic disease often includes HEART DISEASES; STROKE; CANCER; and diabetes (DIABETES MELLITUS, TYPE 2). Chronic Condition,Chronic Illness,Chronically Ill,Chronic Conditions,Chronic Diseases,Chronic Illnesses,Condition, Chronic,Disease, Chronic,Illness, Chronic
D003266 Continuity of Patient Care Health care provided on a continuing basis from the initial contact, following the patient through all phases of medical care. Continuum of Care,Continuity of Care,Care Continuity,Care Continuity, Patient,Care Continuum,Patient Care Continuity
D006699 Home Care Services Community health and NURSING SERVICES providing coordinated multiple services to the patient at the patient's homes. These home-care services are provided by a visiting nurse, home health agencies, HOSPITALS, or organized community groups using professional staff for care delivery. It differs from HOME NURSING which is provided by non-professionals. Domiciliary Care,Home Health Care,Care Services, Home,Home Care,Services, Home Care,Care, Domiciliary,Care, Home,Home Care Service,Service, Home Care
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D016032 Randomized Controlled Trials as Topic Works about clinical trials that involve at least one test treatment and one control treatment, concurrent enrollment and follow-up of the test- and control-treated groups, and in which the treatments to be administered are selected by a random process, such as the use of a random-numbers table. Clinical Trials, Randomized,Controlled Clinical Trials, Randomized,Trials, Randomized Clinical
D058996 Quality Improvement The attainment or process of attaining a new level of performance or quality. Improvement, Quality,Improvements, Quality,Quality Improvements

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