Care Transition Processes to Achieve a Successful Community Discharge After Postacute Care: A Scoping Review

Readmissions to health care facilities are undesirable outcomes that indicate the quality of the care transitions. Although there is a growing evidence-base for preventing readmissions, the focus has been on acute care. Postacute care (PAC) patients are often excluded from these studies, and thus there is limited evidence guiding practitioners' efforts to facilitate an effective community transition after PAC rehabilitation. To provide direction for PAC research and clinical practice, this scoping review summarizes current community transition interventions and identifies practices that facilitate successful community discharge. Thirteen care processes emerged from 35 studies, of which 5 were included in at least 60% of the studies, including coaching on the care transition process, medical self-management, medication self-management, scheduling follow-up medical services, and telephone follow-up. These findings can inform the development, evaluation, and implementation of PAC community transition interventions.