NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Kansagara D, Chiovaro JC, Kagen D, et al. Transitions of Care from Hospital to Home: An Overview of Systematic Reviews and Recommendations for Improving Transitional Care in the Veterans Health Administration [Internet]. Washington (DC): Department of Veterans Affairs (US); 2015 Jan.
Transitions of Care from Hospital to Home: An Overview of Systematic Reviews and Recommendations for Improving Transitional Care in the Veterans Health Administration [Internet].
Show details- 1.
- Stephens C, Sackett N, Pierce R, et al. Transitional Care Challenges of Rehospitalized Veterans: Listening to Patients and Providers. Population Health Management. 2013;16(5):326–331. [PMC free article: PMC3780306] [PubMed: 23560514]
- 2.
- Coleman EA, Parry C, Chalmers S, Min S-J. The care transitions intervention: results of a randomized controlled trial. Archives of Internal Medicine. 2006;166(17):1822–1828. [PubMed: 17000937]
- 3.
- Weaver FM, Perloff L, Waters T. Patients' and caregivers' transition from hospital to home: needs and recommendations. Home Health Care Services Quarterly. 1999;17(3):27–48. [PubMed: 10351068]
- 4.
- Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure. Medical Care. 2005;43(3):246–255. [PubMed: 15725981]
- 5.
- Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine. 2003;18(8):646–651. [PMC free article: PMC1494907] [PubMed: 12911647]
- 6.
- Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine. 2003;138(3):161–167. [PubMed: 12558354]
- 7.
- Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society. 2003;51(4):549–555. [PubMed: 12657078]
- 8.
- Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine. 2004;141(7):533–536. [PubMed: 15466770]
- 9.
- Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine. 2009;360(14):1418–1428. [PubMed: 19339721]
- 10.
- Carey K, Stefos T. An investigation into the cost of VA hospital readmissions. VA Office of Quality, Safety and Value; 2014.
- 11.
- Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA: the Journal of the American Medical Association. 1999;281(7):613–620. [PubMed: 10029122]
- 12.
- James J. Health Policy Brief: Medicare Hospital Readmissions Reductions Program. Nov 12, 2013. [October 13, 2014]. p. 2013. http:
//healthaffairs .org/healthpolicybriefs /brief_pdfs/healthpolicybrief_102.pdf. - 13.
- Medicare.gov. Hospital Compare. 2014. [October 13, 2014]. http://www
.medicare.gov /hospitalcompare/Data/About.html. - 14.
- PACT PCPCIWG. Patient Centered Medical Home Model Concept Paper. Veterans Health Administration Primary Care Services. 2014.
- 15.
- Olson DM, Prvu Bettger J, Alexander KP, et al. Evidence Reports/Technology Assessments, No. 202. Rockville (MD): Agency for Healthcare Research and Quality (US); Oct, 2011. Transition of Care for Acute Stroke and Myocardial Infarction Patients From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention. Report No.: 11(12)-E011. http://www
.ncbi.nlm.nih .gov/books/NBK82455/2011. [PMC free article: PMC4780900] [PubMed: 23126647] - 16.
- Shea BJ, Grimshaw JM, Wells GA, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Medical Research Methodology. 2007;7(1):10. [PMC free article: PMC1810543] [PubMed: 17302989]
- 17.
- Whitlock EP, Lin JS, Chou R, Shekelle P, Robinson KA. Using existing systematic reviews in complex systematic reviews. Annals of Internal Medicine. 2008;148(10):776–782. [PubMed: 18490690]
- 18.
- Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Internal Medicine. 2014.:E2011–2013. Published onlineMay 12, 2014. [PMC free article: PMC4249925] [PubMed: 24820131]
- 19.
- Feltner C, Jones CD, Cene CW, et al. Transitional Care Interventions to Prevent Readmissions for Persons With Heart Failure: A Systematic Review and Meta-analysis. Annals of Internal Medicine. 2014;160(11):774–784. [PubMed: 24862840]
- 20.
- Prvu Bettger J, Alexander KP, Dolor RJ, et al. Transitional care after hospitalization for acute stroke or myocardial infarction: a systematic review. Annals of Internal Medicine. 2012;157(6):407–416. [PubMed: 22986378]
- 21.
- Shepperd S, Lannin NA, Clemson LM, McCluskey A, Cameron ID, Barras SL. Discharge planning from hospital to home. The Cochrane Database of Systematic Reviews. 2013;(1) CD000313. [PubMed: 23440778]
- 22.
- Caplan GA, Sulaiman NS, Mangin DA, Aimonino Ricauda N, Wilson AD, Barclay L. A meta-analysis of “hospital in the home” The Medical Journal of Australia. 2012;197(9):512–519. [PubMed: 23121588]
- 23.
- Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of Internal Medicine. 2013;158(5 Pt 2):397–403. [PubMed: 23460096]
- 24.
- Prieto-Centurion V, Markos MA, Ramey NI, et al. Interventions to reduce rehospitalizations after chronic obstructive pulmonary disease exacerbations. A systematic review. Annals of the American Thoracic Society. 2014;11(3):417–424. [PMC free article: PMC5467116] [PubMed: 24423379]
- 25.
- 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. [PMC free article: PMC2738592] [PubMed: 19189907]
- 26.
- Pandor A, Gomersall T, Stevens JW, et al. Remote monitoring after recent hospital discharge in patients with heart failure: a systematic review and network meta-analysis. Heart (British Cardiac Society). 2013;99(23):1717–1726. [PubMed: 23680885]
- 27.
- Pandor A, Thokala P, Gomersall T, et al. Home telemonitoring or structured telephone support programmes after recent discharge in patients with heart failure: systematic review and economic evaluation. Health Technology Assessment (Winchester, England). 2013;17(32):1–207. v–vi. [PMC free article: PMC4781365] [PubMed: 23927840]
- 28.
- Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. The Cochrane Database of Systematic Reviews. 2006;(4) CD004510. [PMC free article: PMC6823218] [PubMed: 17054207]
- 29.
- Crocker JB, Crocker JT, Greenwald JL. Telephone follow-up as a primary care intervention for postdischarge outcomes improvement: a systematic review. The American Journal of Medicine. 2012;125(9):915–921. [PubMed: 22938927]
- 30.
- Oddone EZ, Weinberger M, Horner M, et al. Classifying general medicine readmissions. Journal of General Internal Medicine. 1996;11(10):597–607. [PubMed: 8945691]
- 31.
- Weinberger M, Oddone EZ, Henderson WG. Does increased access to primary care reduce hospital readmissions? Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. The New England Journal of Medicine. 1996;334(22):1441–1447. [PubMed: 8618584]
- 32.
- Williams JW, Jackson GL, Powers BJ, et al. Closing the quality gap: revisiting the state of the science (vol. 2: the patient-centered medical home). Evidence Report/Technology Assessment. 2012;(208.2):1–210. [PMC free article: PMC4781427] [PubMed: 24422946]
- 33.
- Melton LD, Foreman C, Scott E, McGinnis M, Cousins M. Prioritized post-discharge telephonic outreach reduces hospital readmissions for select high-risk patients. American Journal of Managed Care. 2012;18(12):838–844. [PubMed: 23286612]
- 34.
- Auer R, Gaume J, Rodondi N, Cornuz J, Ghali WA. Efficacy of in-hospital multidimensional interventions of secondary prevention after acute coronary syndrome: a systematic review and meta-analysis. Circulation. 2008;117(24):3109–3117. [PubMed: 18541742]
- 35.
- Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ (Clinical Research Ed.). 2011;343:d6553. (8900488, bmj, 101090866) [PMC free article: PMC3203013] [PubMed: 22034146]
- 36.
- Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAM: the Journal of the American Medical Association. 2011;306(15):1688–1698. [PMC free article: PMC3603349] [PubMed: 22009101]
- 37.
- Fermazin M, Tahan H, Lett II JE, Richards J., Group NPMW. Improving Transitions of Care: Hospital to Home. In: Insight Therapeutics L, editor. National Transitions of Care Coalition. 2009.
- 38.
- Press MJ, Scanlon DP, Ryan AM, et al. Limits of readmission rates in measuring hospital quality suggest the need for added metrics. Health Affairs. 2013;32(6):1083–1091. [PubMed: 23733983]
- 39.
- Kangovi S, Grande D. Hospital readmissions—not just a measure of quality. JAMA: the Journal of the American Medical Association. 2011;306(16):1796–1797. [PubMed: 22028356]
- 40.
- Edwards ST, Prentice JC, Simon SR, Pizer SD. Home-Based Primary Care and the Risk of Ambulatory Care–Sensitive Condition Hospitalization Among Older Veterans With Diabetes Mellitus. JAMA Internal Medicine. 2014;174(11):1796–1803. [PubMed: 25221986]
- 41.
- Amarasingham R, Patel PC, Toto K, et al. Allocating scarce resources in real-time to reduce heart failure readmissions: a prospective, controlled study. BMJ Quality & Safety. 2013;22(12):998–1005. [PMC free article: PMC3888600] [PubMed: 23904506]
- 42.
- Billings J, Dixon J, Mijanovich T, Wennberg D. Case finding for patients at risk of readmission to hospital: development of algorithm to identify high risk patients. BMJ (Clinical Research Ed.). 2006;333(7563):327. [PMC free article: PMC1539047] [PubMed: 16815882]
- 43.
- Mukamel DB, Chou C-C, Zimmer JG, Rothenberg BM. The effect of accurate patient screening on the cost-effectiveness of case management programs. The Gerontologist. 1997;37(6):777–784. [PubMed: 9432994]
- 44.
- Baillie CA, VanZandbergen C, Tait G, et al. The readmission risk flag: Using the electronic health record to automatically identify patients at risk for 30-day readmission. Journal of Hospital Medicine. 2013;8(12):689–695. [PMC free article: PMC4407637] [PubMed: 24227707]
- 45.
- Fihn SD, Box T. Care Assessment Need (CAN) Score and the Patient Care Assessment System (PCAS): Tools for Care Management. VIReC Clinical Informatics Seminar. 2013. [October 2014]. http://www
.hsrd.research .va.gov/for_researchers /cyber_seminars /archives/video_archive .cfm?SessionID=713. - 46.
- Joynt KE, Jha AK. Thirty-day readmissions—truth and consequences. New England Journal of Medicine. 2012;366(15):1366–1369. [PubMed: 22455752]
- 47.
- van Walraven C, Jennings A, Forster AJ. A meta-analysis of hospital 30-day avoidable readmission rates. Journal of Evaluation in Clinical Practice. 2012;18(6):1211–1218. [PubMed: 22070191]
- 48.
- Stefan MS, Pekow PS, Nsa W, et al. Hospital performance measures and 30-day readmission rates. Journal of General Internal Medicine. 2013;28(3):377–385. [PMC free article: PMC3579957] [PubMed: 23070655]
- 49.
- Englander H, Michaels L, Chan B, Kansagara D. The Care Transitions Innovation (C-TraIn) for socioeconomically disadvantaged adults: results of a cluster randomized controlled trial. Journal of General Internal Medicine. 2014:1–8. [PMC free article: PMC4238212] [PubMed: 24913003]
- 50.
- Classen DC, Resar R, Griffin F, et al. ‘Global trigger tool’shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs. 2011;30(4):581–589. [PubMed: 21471476]
- 51.
- Kind AJ, Jensen L, Barczi S, et al. Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital. Health Affairs. 2012;31(12):2659–2668. [PMC free article: PMC3520606] [PubMed: 23213150]
- 52.
- Rau J., The Washington Post. VA Experience Shows Patient 'Rebound' Hard To Counter. 2011. [October 2014]. http://www
.kaiserhealthnews .org/stories/2011 /september/12/va-readmissions.aspx. - 53.
- Rigotti NA, Regan S, Levy DE, et al. Sustained care intervention and postdischarge smoking cessation among hospitalized adults: a randomized clinical trial. JAMA : the journal of the American Medical Association. 2014;312(7):719–728. [PMC free article: PMC4507269] [PubMed: 25138333]
- 54.
- Smeenk FW, van Haastregt JC, de Witte LP, Crebolder HF. Effectiveness of home care programmes for patients with incurable cancer on their quality of life and time spent in hospital: systematic review. BMJ (Clinical Research Ed.). 1998;316(7149):1939–1944. [PMC free article: PMC28590] [PubMed: 9641929]
- 55.
- Vigod SN, Kurdyak PA, Dennis CL, et al. Transitional interventions to reduce early psychiatric readmissions in adults: systematic review. The British Journal of Psychiatry: the Journal of Mental Science. 2013;202(3):187–194. [PubMed: 23457182]
- 56.
- Huntley AL, Thomas R, Mann M, et al. Is case management effective in reducing the risk of unplanned hospital admissions for older people? A systematic review and meta-analysis. Family Practice. 2013;30(3):266–275. [PubMed: 23315222]
- 57.
- Kagedan DJ, Ahmed M, Devitt KS, Wei AC. Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB: the Official Journal of the International Hepato Pancreato Biliary Association. 2014 [PMC free article: PMC4266435] [PubMed: 24750457]
- 58.
- Jackson GL, Powers BJ, Chatterjee R, et al. Improving patient care. The patient centered medical home. A Systematic Review. Annals of Internal Medicine. 2013;158(3):169–178. [PubMed: 24779044]
- 59.
- Kim YJ, Soeken KL. A meta-analysis of the effect of hospital-based case management on hospital length-of-stay and readmission. Nursing Research. 2005;54(4):255–264. [PubMed: 16027568]
- 60.
- Latour CH, van der Windt DA, de Jonge P, et al. Nurse-led case management for ambulatory complex patients in general health care: a systematic review. Journal of Psychosomatic Research. 2007;62(3):385–395. [PubMed: 17324690]
- 61.
- Chiu WK, Newcomer R. A systematic review of nurse-assisted case management to improve hospital discharge transition outcomes for the elderly. Professional Case Management. 2007;12(6):330–336. quiz 337-338. [PubMed: 18030153]
- 62.
- Conroy SP, Stevens T, Parker SG, Gladman JR. A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'. Age and Ageing. 2011;40(4):436–443. [PubMed: 21616954]
- 63.
- Ho PM, Luther SA, Masoudi FA, et al. Inpatient and follow-up cardiology care and mortality for acute coronary syndrome patients in the Veterans Health Administration. American Heart Journal. 2007;154(3):489–494. [PubMed: 17719295]
- 64.
- Oddone EZ, Weinberger M, Giobbie-Hurder A, Landsman P, Henderson W. Enhanced access to primary care for patients with congestive heart failure. Veterans Affairs Cooperative Study Group on Primary Care and Hospital Readmission. Effective Clinical Practice : ECP. 1999;2(5):201–209. [PubMed: 10623052]
- 65.
- Wakefield BJ, Ward MM, Holman JE, et al. Evaluation of home telehealth following hospitalization for heart failure: a randomized trial. Telemedicine Journal and E-health : the Official Journal of the American Telemedicine Association. 2008;14(8):753–761. [PubMed: 18954244]
- 66.
- Fan VS, Gaziano JM, Lew R, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Annals of Internal Medicine. 2012;156(10):673–683. [PubMed: 22586006]
- 67.
- Fitzgerald JF, Smith DM, Martin DK, Freedman JA, Katz BP. A case manager intervention to reduce readmissions. Archives of Internal Medicine. 1994;154(15):1721–1729. [PubMed: 8042889]
- 68.
- Evans RL, Hendricks RD. Evaluating hospital discharge planning: a randomized clinical trial. Medical Care. 1993;31(4):358–370. [PubMed: 8464252]
- 69.
- Kasprow WJ, Rosenheck RA. Outcomes of critical time intervention case management of homeless veterans after psychiatric hospitalization. Psychiatric Services (Washington, D.C.). 2007;58(7):929–935. [PubMed: 17602008]
- 70.
- Cummings JEB, H S, Weaver FM, Manheim LM, Conrad KJ, Nash K, et al. Cost-effectiveness of Veterans Administration hospital-based home care. A randomized clinical trial. Archives of Internal Medicine. 1990;150:1274–1280. [PubMed: 2112906]
- REFERENCES - Transitions of Care from Hospital to Home: An Overview of Systemati...REFERENCES - Transitions of Care from Hospital to Home: An Overview of Systematic Reviews and Recommendations for Improving Transitional Care in the Veterans Health Administration
Your browsing activity is empty.
Activity recording is turned off.
See more...