Transitional care is a set of clinical and communication activities that should occur when patients move from one care setting to another, typically from a hospital to home or to a nursing home. Those most at risk for transitional care problems include elders with multiple medical conditions, dementia, depression, or other mental health disorders; isolated elders without family and friends; non-English speakers, immigrants, or refugees; and those with low incomes.

Studies show that problems associated with transitional care include medication discrepancies (for example, medication prescribed at discharge from the hospital not being noted in outpatient records), missing or illegible transfer documents, insufficient patient education, lack of follow-up appointments, or poor planning for support when the patient returns home. These failures often lead to rehospitalizations that could have been prevented.

This project uses a proven approach developed by a multidisciplinary team at the University of Pennsylvania School of Nursing for reducing preventable rehospitalization of high-risk elders. Funders include the John A. Hartford Foundation, the Langloth Foundation, the Gordon and Betty Moore Foundation, and Kaiser Permanente. CHCF is providing $249,000 to the project to test whether similar outcomes can be achieved using a lower-cost staffing model (using registered nurses instead of nurse practitioners).