Care Transitions: It’s the How, Not Just the What

Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–167. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–1428. Hospital Readmissions Reduction Program. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html. Accessed 16 Jan 2015. Williams MV. A requirement to reduce readmissions: take care of the patient, not just the disease. JAMA. 2013;309(4):394–396. Li J, Young R, Williams MV. Optimizing transitions of care to reduce rehospitalizations. Cleve Clin J Med. 2014;81(5):312–320. Field TS, Ogarek J, Garber L, Reed G, Gurwitz JH. Association of early post-discharge follow-up by a primary care physician and 30-day rehospitalization among older adults. JGIM. 2015;[3106] Sharma G, Kuo Yf Fau - Freeman JL, Freeman Jl Fau - Zhang DD, Zhang Dd Fau - Goodwin JS, Goodwin JS. Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. 20101012 DCOM- 20101115 (1538–3679 (Electronic)). Hernandez AF, Greiner Ma Fau - Fonarow GC, Fonarow Gc Fau - Hammill BG, et al. Relationship between early physician follow-up and 30-day readmission among medicare beneficiaries hospitalized for heart failure. 20100505 DCOM- 20100506 (1538–3598 (Electronic)). Kind AJ, Jencks S, Brock J, et al. Neighborhood socioeconomic disadvantage and 30-day rehospitalization: a retrospective cohort study. Ann Intern Med. 2014;161(11):765–774. Kangovi S, Barg FK, Carter T, et al. Challenges faced by patients with low socioeconomic status during the post-hospital transition. J Gen Intern Med. 2014;29(2):283–289. Hu J, Gonsahn M, Nerenz D. Socioeconomic status and readmissions: evidence from an urban teaching hospital. Health Aff (Project Hope). 2014;33(5):778–785. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–841. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155(8):520–528. Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):433–440. Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. 20140709 DCOM- 20140926 (2168–6114 (Electronic)). Costantino ME, Frey B, Hall B, Painter P. The Influence of a postdischarge intervention on reducing hospital readmissions in a medicare population. Popul Health Manag. 2013;16(5):310–316. Naylor MD, Bowles KH, McCauley KM, et al. High-value transitional care: translation of research into practice. J Eval Clin Pract. 2013;19(5):727–733. Project ACHIEVE. http://www.pcori.org/research-results/2014/project-achieve-achieving-patient-centered-care-and-optimized-health-care. Accessed 21 Jan 2015. Pronovost P Fau - Jha AK, Jha AK. Did hospital engagement networks actually improve care? 20141121 DCOM- 20141125 (1533–4406 (Electronic)).