Abstract
With an aging population and advances in medical science, people with advanced diseases are living longer, and chronic care now dominates the health-care system. Effective management of patients with chronic diseases requires a well-developed care continuum that emphasizes patient safety. Fragmentation and discoordination of health care is a significant cause of inappropriate care and increased health-care costs.
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References
Kansagara D, et al. So many options, where do we start? An overview of the care transitions literature. J Hosp Med. 2016;11(3):221–30.
McCoy KA, Bear-Pfaffendof K, Foreman JK, Daniels T, Zabel EW, Grangaard LJ, Trevis JE, Cummings KA. Reducing avoidable hospital readmissions effectively: a statewide campaign. Jt Comm J Qual Patient Saf. 2014;40(5):198–204.
Lysons W, Coleman E. Transitions of care. Hazzard’s geriatric medicine and gerontology. 6th ed. New York: McGraw-Hill Professional Publishing; 2009.
Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med. 2011;155:520–8. https://doi.org/10.7326/0003-4819-155-8-201110180-00008. http://annals.org/article.aspx?articleid=474993.
Schall M, Coleman E, Rutherford P, Taylor J. How-to guide: improving transitions from the hospital to the clinical office practice to reduce avoidable rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; 2013. Available at www.IHI.org.
Burke R, Kripilani S, Vasileveskis E, Schnipper J. Moving beyond readmission penalties: creating an ideal process to improve transitional care. J Hosp Med. 2013;8:102–9. www.ncbi.nlm.nih.gov/pubmed/23184714.
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009;150(3):178–87.
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):161–7.
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. N Engl J Med. 1996;334(22):1441–7.
Carter JA, Carr LS, Collins J, et al. STAAR: improving the reliability of care coordination and reducing hospital readmissions in an academic medical centre. BMJ Innov. 2015;1(3):75–80.
Hackbarth G, Reischauer R, et al. A path to bundled payment around a rehospitalization. Report to the congress: reforming the delivery system. Washington DC: Medicare Payment Advisory Commission; 2005. p. 83–103.
Hunter T, Nelson JR, Birmingham J. Preventing readmissions through comprehensive discharge planning. Prof Case Manag. 2013;18(2):56–63.
Stevens S. Preventing 30-day readmissions. Nurs Clin North Am. 2015;50(1):123–37.
Peter D, Robinson P, Jordan M, Lawrence S, Casey K, Salas-Lopez D. Reducing readmissions using teach-back: enhancing patient and family education. J Nurs Adm. 2015;45(1):35–42. http://www.ncbi.nlm.nih.gov/pubmed/25479173.
Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA. 2009;301(6):603–18.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–28.
Adams C. Implementation of the re-engineered discharge (RED) toolkit to decrease all-cause readmission rates at a rural community hospital. Qual Manag Health Care. 2014;23(3):169–77.
Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. J Am Geriatr Soc. 2004;52:1817–25.
Greenwald JL, Denham CR, Jack BW. The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. J Patient Saf. 2007;3:97–106.
Kripalani S, Theobald CN, Anctil B, Vasilevskis EE. Reducing hospital readmission rates: current strategies and future directions. Annu Rev Med. 2014;65:471–85.
Leppin A. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095–107.
Jack BW, Paasche-Orlow MK, Mitchell SM, et al. An overview of the Re-Engineered Discharge (RED) Toolkit. (prepared by Boston University under Contract No. HHSA290200600012i). Rockville: Agency for Healthcare Research and Quality; 2013. AHRQ Publication No. 12(13)-0084.
Enderlin C, McLesky N, Rooker J, et al. Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatr Nurs. 2014;34(1):47–52.
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Brown, M.M. (2018). Transitions of Care. In: Daaleman, T., Helton, M. (eds) Chronic Illness Care. Springer, Cham. https://doi.org/10.1007/978-3-319-71812-5_30
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DOI: https://doi.org/10.1007/978-3-319-71812-5_30
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