Researchers at the University of Pennsylvania School of Nursing say they've discovered a robust body of evidence that transitional care, which is a short-term service that bridges gaps between hospital and home, can improve health outcomes and reduce hospital readmissions.

A paper published in Health Affairs, a major public policy journal, highlights a range of solutions to reduce avoidable hospitalizations and health care costs. For that paper, the research team reviewed existing programs to determine what works, for whom, and for how long.

Currently, one in five elderly patients discharged from a hospital is readmitted within a month. Seeking to address the human and substantial financial burden of revolving door hospital readmissions, the Affordable Care Act proposes a number of initiatives to improve care and health outcomes and reduce costs for the growing population of chronically ill people in the U.S. While transitional care is a central theme in these provisions, there is little information available to guide those responsible for implementing these important opportunities.

The review specifically shows that among the common elements of successful transitional-care programs is the use of nurses who work with patients, family caregivers, and health teams to prevent medical errors and assure continuity of care as patients navigate a fragmented care system.

"All nine interventions that showed any positive impact on readmissions relied on nurses as the clinical leader or manager of care," writes lead author Mary Naylor, a registered nurse and a professor at the University of Pennsylvania School of Nursing.

To prevent poor outcomes, transitional care focuses on identifying and addressing patients' and family caregivers' goals, as well as needs for education and support, such as access to community services.

"We have identified a number of strategies that result in short-term benefits and a few that effectively reduced all-cause hospital readmissions through six or 12 months," Naylor says.

She says available evidence provides those responsible for implementing community-based care transitions programs, accountable care organizations, and other innovative delivery and payment models with a strong foundation upon which to build these programs and achieve better care and better outcomes while reducing costs.

"If we capitalize on what we know, the real beneficiaries will be those living with complex chronic conditions and their family caregivers," Naylor says.

Read the Health Affairs article abstract at http://content.healthaffairs.org/content/30/4/746.abstract.