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Related Experiment Videos

Components of Comprehensive and Effective Transitional Care.

Mary D Naylor1, Elizabeth C Shaid1, Deborah Carpenter2

  • 1School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania.

Journal of the American Geriatrics Society
|April 4, 2017
PubMed
Summary

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Effective transitional care (TC) requires addressing eight key components to improve patient outcomes and reduce hospital readmissions. These elements focus on patient and caregiver engagement, education, well-being, and care continuity for Medicare beneficiaries.

Area of Science:

  • Health Services Research
  • Patient-Centered Outcomes
  • Healthcare Quality Improvement

Background:

  • Transitional care (TC) aims to improve patient outcomes and reduce hospital readmissions.
  • Limited understanding exists regarding effective TC elements and their alignment with patient/caregiver needs.
  • Project ACHIEVE addresses this gap by identifying critical TC components.

Purpose of the Study:

  • To identify essential transitional care components for vulnerable Medicare beneficiaries.
  • To align these components with real-world patient and caregiver experiences.
  • To provide evidence-based recommendations for optimizing transitional care.

Main Methods:

  • A national study, Project ACHIEVE, was funded by the Patient-Centered Outcomes Research Institute (PCORI).
Keywords:
accountabilitycomplexity managementcontinuityeducationengagement

Related Experiment Videos

  • A multistakeholder workgroup reviewed published evidence and analyzed patient/caregiver experiences.
  • The workgroup identified and defined preliminary TC components.

    • Main Results:

    • Eight essential transitional care components were identified: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients' and caregivers' well-being, care continuity, and accountability.
    • These components are crucial for achieving desired patient and caregiver outcomes.
    • All identified components require attention for optimal transitional care.

    Conclusions:

    • Health systems must address all eight identified TC components for optimal care.
    • Tailoring attention to each component based on individual needs is essential.
    • Implementing these components can enhance patient outcomes and reduce readmissions.