Research on transitional care: from hospital to home

Concern over the human and financial costs of healthcare "silos" and poorly coordinated care has been growing, fueled by data on risky patient "handoffs," repeat hospitalizations, and avoidable emergency department visits. More than 20% of patients experience an adverse clinical event within 30 days of the discharge from a hospital (). This column features research and review articles focused on the issue of "handoffs" and transitional care. The investigators of the 1st article described studied communication and information transfer deficits between hospitalists and primary care physicians. The 2nd article presents findings of a systematic hospital-based intervention geared toward improving discharge experiences. The 3rd article describes another hospital-based initiative. This reengineered discharge intervention uses nurse discharge advocates as one component of a strategy to help patients understand, develop, and implement their discharge plans. The final article profiled in this column presents findings of a systematic literature review of randomized clinical trials that aimed to improve transitional care for chronically ill adults and opportunities to promote more widespread use of evidence-based programs through initiatives sponsored by the Patient Protection and Affordable Care Act. Interested readers are encouraged to read the articles for full information about the interventions and review findings.