

Department of Veterans Affairs

Health Services Research & Development Service Evidence-based Synthesis Program

Transitions of Care from Hospital to 

Home: An Overview of Systematic 

Reviews and Recommendations for 

Improving Transitional Care in the 

Veterans Health Administration

January 2015

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Quality Enhancement Research Initiative

Health Services Research & Development Service

Washington, DC 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

Portland VA Medical Center

Portland, OR

Devan Kansagara, MD, MCR, Director 

Investigators:

Principal Investigator: 

Devan Kansagara, MD, MCR

Co-Investigators: 

Joseph C Chiovaro, MD

David Kagen, MD

Stephen Jencks, MD, MPH

Kerry Rhyne, MD

Maya O’Neil, PhD

Karli Kondo, PhD

Rose Relevo, MLIS, MS

Makalapua Motu’apuaka, BS

Michele Freeman, MPH

Honora Englander, MD
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

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PREFACE

Quality Enhancement Research Initiative’s (QUERI) Evidence-based Synthesis Program (ESP) 

was established to provide timely and accurate syntheses of targeted healthcare topics of 

particular importance to Veterans Affairs (VA) clinicians, managers and policymakers as they 

work to improve the health and healthcare of Veterans. The ESP disseminates these reports 

throughout the VA, and some evidence syntheses inform the clinical guidelines of large 

professional organizations. 

QUERI provides funding for four ESP Centers and each Center has an active university 

affiliation. The ESP Centers generate evidence syntheses on important clinical practice topics, 

and these reports help: 

• develop clinical policies informed by evidence;

• guide the implementation of effective services to improve patient

outcomes and to support VA clinical practice guidelines and performance

measures; and

• set the direction for future research to address gaps in clinical knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of HSR&D Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, the 

Center established a Steering Committee comprised of QUERI field-based investigators, VA 

Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP 

Coordinating Center Program Manager, at Nicole.Floyd@va.gov. 

Recommended citation: Kansagara D, Chiovaro JC, Kagen D, Jencks S, Rhyne K, O’Neil M, 

Kondo K, Relevo R, Motu’apuaka M, Freeman M, Englander H. Transitions of care from 

hospital to home: a summary of systematic evidence reviews and recommendations for 

transitional care in the Veterans Health Administration. VA-ESP Project #05-225; 2014. 

This report is based on research conducted by the Evidence-based Synthesis Program (ESP) 

Center located at the VA Portland Health Care System, Portland, OR, funded by the Department 

of Veterans Affairs, Veterans Health Administration, Office of Research and Development, 

Quality Enhancement Research Initiative. The findings and conclusions in this document are 

those of the author(s) who are responsible for its contents; the findings and conclusions do not 

necessarily represent the views of the Department of Veterans Affairs or the United States 

government. Therefore, no statement in this article should be construed as an official position of 

the Department of Veterans Affairs. No investigators have any affiliations or financial 

involvement (eg, employment, consultancies, honoraria, stock ownership or options, expert 

testimony, grants or patents received or pending, or royalties) that conflict with material 

presented in the report. 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

TABLE OF CONTENTS 

Preface.............................................................................................................................................. i 

Executive Summary ........................................................................................................................ 1 

Introduction ................................................................................................................................. 1 

Methods ....................................................................................................................................... 1 

Results ......................................................................................................................................... 1 

Which transitional care intervention characteristics are associated with reductions in 

readmission rates? .................................................................................................................... 2 

Do the effects of transitional care interventions vary depending on the setting in which they 

are implemented? ..................................................................................................................... 2 

How does the choice of patient population targeted influence the effects of transitional care 

interventions?........................................................................................................................... 2 

Discussion ................................................................................................................................... 3 

Summary of findings ............................................................................................................... 3 

Policy implications .................................................................................................................. 4 

Future research ........................................................................................................................ 4 

Limitations ............................................................................................................................... 4 

Conclusions ............................................................................................................................. 5 

Background ..................................................................................................................................... 6 

Methods........................................................................................................................................... 7 

Results ............................................................................................................................................. 9 

What transitional care intervention characteristics are associated with reductions in 

readmission rates? .................................................................................................................... 9 

Do the effects of transitional care interventions vary depending on the setting in which they 

are implemented? ................................................................................................................... 12 

How does the choice of patient population targeted influence the effects of transitional care 

interventions?......................................................................................................................... 12 

Discussion ..................................................................................................................................... 14 

Summary of findings ................................................................................................................. 14 

Policy implications .................................................................................................................... 15 

Understand the spectrum of care transitions activities and diagnose systems gaps .............. 15 

Care transitions and PACT .................................................................................................... 16 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

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Consider targeting high-risk populations .............................................................................. 17

Measure outcomes beyond 30 day readmissions ................................................................... 18

Implementation considerations .............................................................................................. 19

Critically assess the current system of post-discharge telephone calls ................................. 19

Future research and quality improvement work ........................................................................ 20

Limitations ................................................................................................................................ 21

Conclusions ............................................................................................................................... 22

REFERENCES ............................................................................................................................. 23

Appendix A. Tables ...................................................................................................................... 29

Table 1. Characteristics and Key Findings of Systematic Reviews of Care Transitions, by 

Patient Population .................................................................................................................. 29

Table 2. Characteristics and Key Findings of Systematic Reviews of Care Transitions, by 

Intervention Type .................................................................................................................. 32

Table 3. Clinical Outcomes, Utilization Outcomes, and Implementation Considerations in 

Systematic Reviews of Care Transitions, by Patient Population ........................................... 35

Table 4. Clinical Outcomes, Utilization Outcomes, and Implementation Considerations in 

Systematic Reviews of Care Transitions, by Intervention Type ........................................... 37

Table 5. Studies of Care Transition Interventions Conducted in VA settings ...................... 43

Appendix B. Search Strategy ........................................................................................................ 46

Appendix C. Figures ..................................................................................................................... 48

Figure 1. Literature Flow Diagram ........................................................................................ 48

Figure 2. Transitional Care Map ............................................................................................ 49

Appendix D. Inclusion/Exclusion Criteria .................................................................................... 51

Appendix E. Reviewer Comments and Responses ....................................................................... 53

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

EXECUTIVE SUMMARY

INTRODUCTION

Health care systems are increasingly focused on efforts to reduce hospital readmissions; a wide 

variety of evidence exists on interventions to reduce readmissions, and national and local quality 

improvement efforts focused on transitional care have also been developed. 

Transitional care interventions can be resource intensive, however, and can include many 

different components. For health systems that endeavor to improve the transitional care 

experience for their patients, it is a challenge to define the specific nature of interventions they 

should adopt, as well as which patient populations they should target. 

This report broadly summarizes evidence examining the effects of transitional care interventions. 

In particular, the report identifies key themes that have emerged across the transitional care 

intervention literature that clarify which types of intervention are associated with reduced 

readmissions and/or mortality, whether intervention effects differ depending on the setting in 

which they are implemented, and whether effects differ across patient populations. Additionally, 

we outline potential policy implications based on the themes emerging from the evidence as well 

as our own clinical, research, and policy experience with transitional care within the Veterans 

Health Administration (VHA). 

METHODS

We conducted a review of published systematic reviews. We were broadly inclusive of many 

types of interventions, but focused on reviews that reported hospital readmissions as an outcome, 

regardless of whether it was the primary outcome. Within each patient population or intervention 

type of interest, we identified the most recent and comprehensive reviews meeting key quality 

criteria. We also examined the effects of transitional care activities within the context of the 

medical home, given its relevance to the current VA practice environment. 

One investigator reviewed titles and abstracts for relevance. Two investigators independently 

reviewed potentially relevant full-text articles for inclusion. Any disagreements were resolved 

through consensus. 

From each review we abstracted characteristics of the study population, outcomes, and 

intervention, as well as any data that would inform intervention implementation. Narrative 

syntheses were compiled for distinct patient populations and intervention types. These narratives 

were reviewed independently by each of the authors of this report, who then identified key 

themes in the evidence as well as recommendations for stakeholders based on their interpretation 

of the narratives. Policy implications were informed by interpretation of the evidence in the 

context of the clinical and research experience of different members of the study team. 

RESULTS

We reviewed 807 titles and abstracts from the electronic search, and identified an additional 125 

from reviewing reference lists and performing manual searches for recently published and 

unpublished or ongoing studies. Eighty-three systematic reviews met our inclusion criteria and, 

of these, we selected 17 that were most recent and broadly scoped. Seven reviews focused on 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

specific patient populations, and another 10 reviews were organized according to intervention 

type. 

Which transitional care intervention characteristics are associated with 

reductions in readmission rates? 

Overall, it is very difficult to identify specific intervention characteristics that are necessary for 

successful care transitions. There is some consistency among different patient populations and 

settings that successful interventions are more comprehensive, involve more aspects of the care 

transition, extend beyond the hospital stay, and are flexible enough to respond to individual 

patient needs. However, the strength of evidence supporting these overarching conclusions 

should be considered low because these conclusions are derived from indirect, post-hoc 

comparisons that include many different types of interventions implemented in a variety of ways 

among dissimilar populations and clinical settings. We found very little comparative 

effectiveness data. 

Do the effects of transitional care interventions vary depending on the setting in 

which they are implemented? 

The design of an intervention and its effects may depend on factors such as the presence of a 

shared electronic medical record, access to community resources, integration of primary and 

hospital care, and the presence of a medical home. However, we found no evidence directly 

examining whether an intervention’s effectiveness depends on the health system context within 

which it is implemented. Moreover, the transitional care literature generally provided only scant 

descriptions of the health system context of the interventions. We identified 9 studies conducted 

in VA settings. Overall, there is no clear pattern of effect differences between studies conducted 

in VA and non-VA settings. 

Transitions of care and the patient-centered medical home

A 2012 review included 31 studies of PCMH interventions, which commonly included hospitalto-home transitional care coordination. The authors found moderate-strength evidence that 

PCMH interventions were associated with higher patient-reported levels of care coordination. 

They found low-strength evidence that PCMH interventions decreased emergency room use, 

though it is unclear which components of the PCMH mediated this effect. By contrast, they 

found low-strength evidence that PCMH had no effect on hospital admissions. 

How does the choice of patient population targeted influence the effects of 

transitional care interventions? 

Many of the studies in these reviews identified high-risk patients for inclusion based simply on 

age, comorbidity, and/or prior utilization characteristics. The relative importance of careful 

patient selection compared to intervening in unselected populations is unclear, in part because 

most studies used some degree of patient selection and few reviews explicitly examined effects

based on patient selection. 

We found inconsistent results among reviews examining interventions in specific populations. 

General medical, geriatric, and congestive heart failure (CHF) patients have been the most 

frequently studied and there are several types of interventions that have been effective in these 

populations. On the other hand, there is little evidence that COPD patients benefit from 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

transitional care interventions, though most of the interventions took place only in the postdischarge setting. There was not enough good-quality literature in mental health or surgical 

populations to draw firm conclusions. 

DISCUSSION 

Summary of findings

We examined 17 systematic reviews across different patient populations and representing a 

variety of intervention types in order to provide a broad overview of the care transitions 

literature. While there have been numerous examples of interventions that reduced readmission 

rates, there were no patient population or intervention type categories within which transitional 

care interventions were uniformly successful. 

It is not surprising that there are many sources of heterogeneity in a field as broadly defined as 

transitional care. Variation in populations studied, intervention characteristics, personnel, 

outcomes measured, and settings make it difficult to identify definitive recommendations for a 

specific intervention that should be broadly applied. Nevertheless, we were able to draw several

generalizations from the literature. 

1) Interventions that address more components of the care transition are probably better than

those that address fewer.

2) Successful interventions tended to include the means to assess and respond to individual

peri-discharge needs.

3) There is very little data supporting the effectiveness of interventions isolated to either the

pre- or post-discharge settings. Successful interventions which were largely implemented

in one setting often included components (such as home visits, a single point of contact,

and/or telephone calls) that bridged settings. On the other hand, in select populations such

as patients with CHF, there is some evidence supporting post-discharge interventions

such as structured telephone support and multidisciplinary CHF clinics.

4) It is not clear to what extent and for whom post-discharge home visits are a necessary

component of care transitions.

5) The vast majority of the care transitions literature has been hospital-focused, with very

little literature examining the role of primary care teams during the transitions of care.

There is a growing literature examining the effects of medical home interventions, most

of which include cross-site care coordination activities; however, the characteristics of

successful care transitions within the medical home context have not been well explored.

6) Many interventions that have demonstrated a reduction in readmission rates have

included patients at high risk for readmission because of underlying comorbidities such

as CHF and/or because of additional factors such as prior utilization.

7) Interventions designed to address the needs of patients with complex, chronic medical

illness have been the best studied. It is unclear whether the success of some interventions

studied in these patient populations reflects the content expertise that intervention

personnel might develop in working with specific patient populations, higher baseline

risk of poor outcomes among these patients, or sensitivity of chronic medical illness to

transitional care improvements. However, there are many notable exceptions even among

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patients with chronic medical illness – for example, we found little evidence of benefit in 

COPD populations, though many transitional care components were absent in these 

studies. There is little good-quality transitional care literature in mental health or surgical 

populations. 

8) Reviews that examined effects by year of publication suggest that many of the

interventions demonstrating benefit were conducted more than a decade ago.

9) In order to allow for better collation of results from trials, development of a standard

taxonomy is needed. This taxonomy should include both population descriptors as well as

intervention descriptors.

Policy implications

In the main report, we present several policy implications along with a brief discussion and 

rationale for each. There are likely many steps of the care transition that, if missed, could hinder 

the quality of the care transition. We recommend each institution use a standardized approach to 

diagnose transitional care gaps. We have included a transitional care “map” that could be used 

for such assessments. We do not suggest that each step is necessary for every patient. We also 

suggest that the VHA could harness existing infrastructures such as PACT and home-based 

primary care to accomplish pieces of the care transition that had previously been accomplished in 

the intervention literature by additional transitional care nurses. Because some transitional care 

intervention activities can be resource intensive, we provide some discussion about the potential 

merits and pitfalls of risk assessment to identify high-risk patients for intervention. Finally, we 

suggest the VHA critically examine the current broad-based implementation of post-discharge 

telephone calls. 

Future research

In general, there is an overarching need for better evidence to guide selection and 

implementation of complex, multicomponent transitional care interventions in different settings. 

One of the major weaknesses of the transitional care literature is the marked variation in 

intervention definitions, timing of outcome follow-up, and descriptions of interventions and 

usual care. As VA conducts more research in this field, use of taxonomies to guide study design 

and description may help standardize reporting. In addition to this work, there are a number of 

more specific areas of investigation listed in the main report, including an urgent need for more 

work in mental health and surgical populations, a need for more comparative effectiveness 

research, and the development of continuous quality improvement mechanisms that integrate 

inpatient and outpatient personnel. 

Limitations

Our intent was to provide a broad overview of a complex literature, and to identify emerging 

themes that could help to define policy recommendations. However, we acknowledge that our 

chosen approach has a number of important limitations including its broad scope rather than indepth analysis; the lack of formal strength of evidence ratings for our summary conclusions, 

though we suggest the overall strength of evidence be considered low; our use of readmissions 

outcomes as an inclusion criteria; and our reliance on previous systematic reviews which might 

not include more recently published studies. Our policy recommendations are informed by 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

evidence but also incorporate practical considerations and our own experience, and therefore are 

partly subjective in nature. 

Conclusions

The literature includes many different types of interventions, studied in varied populations and 

clinical settings, and implemented in different ways, but there is no commonly used taxonomy 

describing the various factors. Furthermore, there is very little comparative effectiveness data. It 

is, therefore, very difficult to identify specific intervention components and characteristics that 

are necessary for successful care transitions. In general, successful interventions are more 

comprehensive, touch on more aspects of the care transition, extend beyond the hospital stay, 

and are flexible enough to respond to individual patient needs. Transitional care interventions 

have not been well studied within integrated health systems and within the medical home 

context. Future work should focus on how best to incorporate outpatient teams into transitional 

care improvement processes. 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

EVIDENCE REPORT

BACKGROUND

The hospital-to-home transition marks an abrupt shift from intensive, provider-driven care to 

self-managed care, and, often, from one set of inpatient providers to an entirely different set of 

outpatient providers. After hospital discharge, patients in both VA and non-VA settings are 

uncertain how to manage their health care.1-3 They are also at increased risk for adverse events,

4-6

and for hospital readmissions which are common and costly.5-9 About one in 5 older Medicare 

beneficiaries is readmitted within 30 days of hospital discharge at an annual estimated cost of 

$17 billion. Similarly, 15-20% of Veterans hospitalized with higher-risk conditions such as 

congestive heart failure (CHF), chronic obstructive pulmonary disease, or myocardial infarction 

are readmitted within 30 days, while nearly one-quarter of those with chronic mental illness 

experiences a 30 day readmission.10 In 2011, the total cost of 30 day readmissions to the 

Veterans Health Administration (VHA) was $1.2 billion.10 

Transitional care has been defined as “a set of actions designed to ensure the coordination and 

continuity of healthcare as patients transfer between different locations or different levels of care 

within the same location.”7

 Early studies showed that nurse-led transitional care interventions 

beginning in the hospital and continuing after discharge had the potential to reduce the rate of 

hospital readmissions.2,11 Given the promise of these early interventions and several subsequent 

Center for Medicaid and Medicare Service (CMS) policy initiatives designed to help promote 

uptake of transitional care quality improvements,12,13 transitional care intervention studies have 

proliferated in recent years. 

Currently, like many health systems, the VHA must decide how to approach care transitions. In 

2010, VHA began a nationwide effort to implement a version of the medical home model of 

care, called Patient Aligned Care Teams (PACT), in which care coordination is a key principle.14

The VHA has also instituted a goal to have PACT nurse care managers call most patients within 

2 business days of hospital discharge. There is no other broadly adopted approach to transitional 

care in VA settings. Further transitional care efforts might require additional investment in 

transitional care, but the benefits of such interventions in VA settings and for Veteran 

populations are not well understood. 

Transitional care interventions are complex and often involve multiple components. The 

potential success or failure of these complex health systems interventions may depend on the 

nature of the interventions themselves, the settings in which they were implemented, and/or the 

populations included. This report aims to broadly summarize the effects of transitional care 

interventions in different patient populations and settings, as well as the effects of particular 

types of transitional care interventions on readmission rates and mortality. We also identify key 

themes about implementing transitional care interventions that have emerged across the 

literature, and provide some practical recommendations to improve care transitions in VHA and 

guide future research. 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

METHODS 

We conducted a review of published systematic reviews. “Transitional care” is a loose, broadly 

defined term that can be applied to many different types of interventions and has been studied in 

many different patient populations. We use the term “intervention type” to refer to single- or 

multicomponent interventions that used a similar approach or bundle of care processes (eg, 

telemonitoring, hospital-at-home), or addressed a similar aspect or key process of the care 

transition (eg, medication reconciliation). Patient populations are defined according to clinical 

condition (eg, CHF) or demographic characteristics (eg, geriatric). There are numerous 

characteristics that further distinguish interventions from one another. “Intervention 

characteristics” refer to any of the following (derived from an existing taxonomy)15: transition 

type (hospital to home, hospital to nursing facility), intervention target (patient, caregiver), key 

processes (education, personal health record), key personnel involved (nurse, social worker), 

method of contact (phone, home visits), and intensity and complexity. 

From an initial review of the literature, we recognized that most systematic reviews typically 

either examined different transitional care intervention types in a given patient population, or 

examined a given intervention type in a variety of patient populations. We identified categories 

of patient populations and intervention types to help guide our literature search, study selection, 

and synthesis (Appendix A, Tables 1 and 2). The intervention type and patient population 

categories were developed iteratively with input from a panel of content experts, a “horizon 

scan” of the literature, and with input from our study team. The search strategy is presented in 

Appendix B. 

We focused on reviews that reported hospital readmissions as an outcome, regardless of whether 

it was the primary outcome. However, we summarized other outcomes reported by each review. 

Within each patient population or intervention type of interest, we first identified reviews that 

fulfilled key quality criteria: 1) clearly reported their search strategy, 2) reported inclusion and 

exclusion criteria, and 3) conducted an appraisal of the internal validity of the included trials.16,17

If there was more than one review within each category fulfilling these criteria, we prioritized the 

most recent review and, if there were several recent reviews meeting quality criteria, we 

prioritized those with the broadest scope. We discussed the ultimate choice of review as a group 

and resolved any disagreements through consensus. 

Because of its relevance to the current VA practice environment, we also reviewed medical 

home literature to examine the effects of transitional care activities within the context of the 

medical home (see search strategy, Appendix B). 

From each review we abstracted search dates, inclusion criteria, patient population 

characteristics, readmission and mortality outcomes, other clinical and utilization outcomes, and 

any data that would inform intervention implementation (ie, characteristics of the setting or the

intervention that modified the effect of the intervention). We also developed brief narrative 

summaries of findings for each patient population or intervention type. These narratives were 

compiled into a single document and reviewed independently by each of the authors of this 

report, who then compiled a brief list of key themes in the evidence as well as recommendations 

for stakeholders based on their interpretation of the narratives. 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Policy implications were informed by interpretation of the evidence in the context of clinical and 

research experience of different members of the study team, which includes: experience with 

implementation and evaluation of transitional care interventions (DLK, HE), readmissions policy 

research (DLK, SJ, HE, DK), medical home implementation and evaluation in VA (DLK), 

administrative leadership (DK, HE), inpatient clinical practice in VA (DLK, DK, JC, KR) and 

non-VA settings (HE), outpatient clinical practice in VA (DLK) and non-VA settings (HE), and 

policy development at federal and state levels (SJ).

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

RESULTS

We reviewed 807 titles and abstracts from the electronic search, and identified an additional 94 

from reviewing reference lists and performing manual searches for recently published and 

unpublished or ongoing studies (Appendix C, Figure 1). Eighty-one systematic reviews met our 

inclusion criteria and, of these, we selected 17 that were the most recent and broadly scoped. 

We selected a representative review for 7 patient populations and 10 intervention types. The 

effects of transitional care interventions on hospital readmissions and mortality are summarized 

in Tables 1 and 2 (Appendix A). The effects of interventions on other clinical and utilization 

outcomes are summarized in Tables 3 and 4 (Appendix A), along with any information from the 

reviews relevant to implementation considerations (setting or intervention characteristics). All 

reviews used reproducible systematic searches, specified inclusion and exclusion criteria, and 

assessed the quality of included studies (most using established criteria – see Tables 1 and 2). 

Almost none of the reviews, however, rated the strength of the overall body of evidence. 

WHAT TRANSITIONAL CARE INTERVENTION CHARACTERISTICS 

ARE ASSOCIATED WITH REDUCTIONS IN READMISSION RATES? 

Overall, it is very difficult to identify specific intervention characteristics that are necessary for 

successful care transitions. There is some consistency among different patient populations and 

different settings that successful interventions are more comprehensive, touch on more aspects of 

the care transition, extend beyond the hospital stay, and are flexible enough to respond to 

individual patient needs. However, the strength of evidence supporting these overarching 

conclusions should be considered low because these are indirect, post-hoc comparisons across 

literature that includes many different intervention types, studied in varied populations and 

clinical settings, and implemented in different ways. We found very little comparative 

effectiveness data. 

Transitions of care taxonomies

Two reviews developed detailed taxonomies to guide their analysis of the literature.15,18 One 

review examined transitional care interventions in patients with stroke or MI, and explicitly set 

out to define the key characteristics of interventions and to determine whether outcome effects 

were modified by intervention, patient, or system characteristics.15 Their taxonomy specifies a 

number of intervention characteristics including: 1) transition type (hospital to home, nursing 

facility to home), 2) intervention target (patient, caregiver, or provider), 3) key processes 

(education, counseling, etc), 4) key personnel involved, 5) method of contact, 6) intensity and 

complexity, and 7) outcomes targeted. 

Despite the development of a detailed taxonomy and a large number of fair- and good-quality 

trials, the authors were unable to draw firm conclusions about which intervention characteristics 

are associated with benefit, and how population and health system setting characteristics might 

modify effects. They cited inconsistency in intervention and usual care definitions, lack of 

statistical power, variation in study endpoints, methodologic shortcomings of some studies, and 

limited generalizability (most studies were single-site and non-US) as key limitations to the body 

of evidence. 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

A more recent review developed a similar type of taxonomy. The authors also systematically 

characterized intervention intensity by creating a “comprehensive support” variable which was 

based on number of patient interactions, number of personnel involved, number of intervention 

components, and the ability of the intervention to address self-management needs. A metaregression including 42 trials, the vast majority of which included general medical patients or 

patients with CHF and were considered to be methodologically sound, found interventions were 

overall associated with reductions in readmissions (pooled RR 0.82, 95%CI 0.73-0.91). They 

found the observed benefits were mostly contributed by interventions with the most 

comprehensive support (RR readmission in the 7 studies with highest comprehensive support 

scores compared to 15 studies with the lowest scores, 0.63, 95% CI 0.43-0.91). They also found 

that the observed benefit was mainly limited to studies published before 2002 (RR readmission 

of studies published in 2002 or after, 1.47, 95% CI 1.10-1.96). They speculate that, over the last 

decade, usual care has improved, making it more difficult to demonstrate the incremental benefit 

of transitional care interventions. 

The effects of different intervention types

An Agency for Healthcare Research and Quality (AHRQ) review in patients with CHF

categorized interventions into one of 6 types: home-visiting programs, structured telephone 

support, telemonitoring, outpatient clinic-based (which included multidisciplinary CHF clinics, 

primarily educational, and other).19 This review found interventions with multidisciplinary HF 

clinic visits or home visits reduced both all-cause readmissions and mortality, with NNTs below 

10 for readmission and 18-33 for mortality (for MDS-HF clinic and home visiting programs, 

respectively). Structured telephone support interventions produced a similar mortality benefit but 

did not reduce all-cause readmissions. The authors of this CHF review found that, across 

intervention types, the key processes of care that seemed to be associated with reduced 

readmissions included: self-management education delivered in person, early post-discharge 

contact, a point of post-discharge contact, and the ability to individually tailor the intervention. 

One review of patients with stroke or myocardial infarction described 5 intervention types: 1) 

hospital-based discharge preparation, 2) hospital-based patient and family education, 3) 

community-based patient and family education, 4) community-based models of support 

interventions, and 5) chronic disease management models of care.20 They found moderatestrength evidence that early supported discharge of stroke patients (short hospital stay followed 

by intensive home care with a multidisciplinary team) shortened length of stay without adversely 

impacting readmissions or mortality. Specialty care after an MI was associated with reduced 

mortality, but the strength of evidence was low (largely from one VA observational study). 

Tables 2 and 4 summarize reviews focused on specific intervention types (Appendix A). Several 

show promise in reducing readmissions and/or mortality.21-23 Many of the more successful 

interventions, in reality, touched on numerous aspects of the care transition and took place across 

settings. For example, according to a Cochrane review updated in 2013, there is moderatestrength evidence that structured and individually tailored discharge planning reduces 

readmissions within 90 days, and hospital length of stay.21 However, the discharge planning 

interventions were likely complex and included numerous care processes, with substantial 

variation among studies in the exact combination of care processes used. In 9 of the 

interventions, a nurse “advocate” helped with discharge planning activities and care 

coordination. Twelve of the interventions included post-discharge follow-up. 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

By contrast, a review of COPD patients found 5 trials of interventions that began after hospital 

discharge and did not include many care processes – such as provider continuity, ensuring postdischarge follow-up, and patient-centered discharge education – that have been part of 

interventions that were successful in other populations. The interventions did not consistently 

reduce readmissions or mortality.24

Kwan et al examined peri-discharge medication reconciliation interventions.23 They found one 

intervention that reduced clinically significant adverse drug events (ADE) and post-discharge 

utilization, but this intervention included additional care processes such as post-discharge followup.25 They otherwise found that interventions focused largely on medication reconciliation found 

many clinically significant unintended discrepancies (median proportion of patients with at least 

one discrepancy, 45%), but little evidence that these focused interventions impacted utilization or 

reduced ADE. 

Home visits

It is unclear whether home visits are a necessary component of transitional care interventions. A 

meta-analysis of trials including general medicine or CHF patients did not find that the setting of 

care delivery influenced outcomes; however, all but one of the most comprehensive interventions 

included home visits in their model.18 On the other hand, the CHF review discussed above found 

evidence in support of interventions that did and did not include a home visit component.19 They 

found insufficient evidence directly comparing interventions with and without home visits. 

Hospital-at-home interventions were associated with reductions in readmissions and mortality 

across 61 trials, among which medical populations were best studied.22 Specific components of 

the included interventions were not well-described, and periods of observation for outcomes 

were not specified. Interventions were associated with greater patient and caregiver satisfaction 

in the vast majority of studies reporting such outcomes. The interventions examined in this 

review were largely designed to substitute home care for part or all of a hospitalization, though 

the degree of “admission substitution” did not appear to be associated with differences in effects. 

Of note, similar to the Leppin review, they found that much of the observed benefit was found in 

studies published before 2003.22 

Telephone-based and telemonitoring interventions

One review focused on post-discharge remote monitoring, mostly with telephone, in patients 

with CHF.

26,27 Similar to the 2014 AHRQ CHF review referenced above, there were 2 types of 

telephone interventions described: structured telephone support and telemonitoring. Structured 

telephone support (STS) interventions typically included periodic scripted telephone calls from 

nurses to review symptoms, interval physiologic data such as weight, and self-management 

skills. Telemonitoring interventions, on the other hand, focused on remote monitoring of 

physiologic data and, typically, further phone contact was only triggered by abnormal vital signs 

or weights. STS interventions reduced long-term (≥ 6 month), but not short-term (2-3 month) 

heart failure readmissions, and were associated with reduced long-term mortality.

19,27 Though 

one review noted a trend towards reduced mortality with telemonitoring interventions, both 

reviews noted the substantial methodologic shortcomings of this literature and the inconsistency 

of results across studies. The AHRQ review found insufficient evidence (one methodologically 

flawed trial) of the comparative effectiveness of STS and telemonitoring interventions. 

11
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Two reviews examined the effects of post-discharge follow-up calls. An older Cochrane review 

from 2006 focused on calls performed by hospital-based personnel.28 Though 33 studies 

including 5,110 patients were included in this review, there was inconclusive evidence of the 

effectiveness of these interventions, largely because of the low methodologic quality of most 

included studies. A more recent review included 3 studies of calls delivered by primary care 

personnel.29 The authors of this review similarly concluded there was insufficient evidence of the 

effects of post discharge calls on utilization, though they did find that the interventions were 

associated with higher rates of primary care engagement. 

Do the effects of transitional care interventions vary depending on the setting in 

which they are implemented? 

Theoretically, the design of an intervention and its effects might depend on factors such as the 

presence of a shared electronic medical record, access to community resources, integration of 

primary and hospital care, and the presence of a medical home. However, we found no evidence 

directly examining whether intervention effectiveness depends on the health system context 

within which they are implemented. Moreover, the transitional care literature generally has 

provided only scant descriptions of the health system context of the interventions. 

VA studies

From the reviews included in our report, we identified 9 studies conducted in VA settings 

summarized in Table 5 (Appendix A). Overall, there is no clear pattern of effect differences 

between studies conducted in VA and non-VA settings, but there are relatively few studies. Of 

note, 2 studies examining the effects of increasing primary care access were conducted in VA 

settings – both actually found an increased risk of readmissions.30,31

Transitions of care and the patient-centered medical home

A recent review for AHRQ included 31 studies of PCMH interventions, most of which included 

care coordination activities – most commonly, hospital-to-home transitional care coordination.32

The authors found moderate-strength evidence that PCMH interventions were associated with 

higher patient-reported levels of care coordination. They found low-strength evidence that 

PCMH interventions lowered emergency room use, though it is unclear which components of the 

PCMH mediated this effect. On the other hand, they found low-strength evidence that PCMH 

had no effect on hospital admissions (readmissions were not reported separately). 

How does the choice of patient population targeted influence the effects of 

transitional care interventions? 

The relative importance of careful patient selection, as compared to intervening on an unselected 

group of patients, is unclear. Many studies in these reviews used inclusion criteria which selected 

patients who were at high risk for readmission because of older age, significant medical 

comorbidity, and/or a history of high utilization. However, few reviews explicitly examined 

variation of intervention effects based on patient criteria. One review found studies that did and 

did not use high-risk patient selection criteria had similar results.23 A meta-regression of trials 

including general medical or CHF populations did not find significantly different effects between 

studies without age restrictions and those which included only patients over 65 years of age 

(interaction p = 0.24).18 Similarly, a review of hospital-at-home studies did not find a clear 

difference in effects among studies in patients younger than 70, 70-73, and older than 74 years.22

12
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

While many studies identified high-risk populations based on simple inclusion criteria, almost no 

studies explicitly used multivariable readmission risk prediction tools to identify high-risk 

patients for inclusion. We found one review with one trial comparing the effects of riskprioritized post-discharge telephone calls to unprioritized calls.33 Groups were randomized and 

matched on key demographic and comorbidity characteristics. The call structure and health care 

team were the same in both groups, but calls in the intervention group were delivered first to the 

sickest patients as defined by an electronic utilization prediction tool. Calls in the intervention 

group were delivered sooner. There were significantly fewer readmissions in the intervention 

group over 30 days. 

Some of the reviews also speculated that focusing on specific groups of patients allowed diseasespecific customization of interventions and supported expertise development. For example, one 

review found that interventions in acute myocardial infarction patients which focused on 

effective use of disease-specific medications were associated with a mortality benefit, though 

this was largely driven by one study.34 Another review examining comprehensive geriatric 

assessment interventions found that gains in the combined outcome of mortality and functional 

decline were only associated with interventions delivered in a geriatric ward setting.35 The 

authors speculate that the multidisciplinary team of providers developed more expertise and 

facility with the patient population. 

We found inconsistent results among reviews examining interventions focused on specific 

populations. There were several types of interventions that improved readmissions and/or 

mortality in CHF patients.19 Multidisciplinary post-discharge heart failure clinics were associated 

with reduction in readmissions, while primary care based follow-up interventions did not 

improve outcomes. In one review of studies in COPD patients there was no consistent evidence 

of benefit, and one of the interventions was associated with increased mortality. However, the 

vast majority of intervention components in these studies took place after hospital discharge so it 

is unclear if the differences in results between CHF and COPD populations relate to patient 

population or the interventions themselves. There was not enough good-quality literature in 

mental health or surgical populations to draw firm conclusions. 

13
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

DISCUSSION 

SUMMARY OF FINDINGS

We examined 17 systematic reviews across different patient populations and representing a 

variety of intervention types in order to provide a broad overview of the care transitions 

literature. While there have been numerous examples of interventions that have been successful 

in reducing readmission rates, there were no patient population or intervention categories within 

which transitional care interventions were uniformly successful. 

It is not surprising that there are many sources of heterogeneity in a field as broadly defined as 

transitional care. Variations in population studied, intervention definition, personnel, outcome 

definition, and setting make it difficult to identify definitive recommendations in support of a 

specific intervention type that should be broadly implemented. Nevertheless, there are several 

important generalizations we drew from the literature. 

1) Interventions that address more components of the care transition are probably better than

those that address fewer.

2) Successful interventions tended to include the means to assess and respond to individual

peri-discharge needs.

3) There is very little data supporting the effectiveness of interventions isolated to either the

pre- or post-discharge settings. Successful interventions which were largely implemented

in one setting still often included components (such as home visits, a single point of

contact, and/or telephone calls) that bridged settings. On the other hand, in select

populations – such as patients with CHF – there is some evidence supporting postdischarge interventions such as structured telephone support and multidisciplinary CHF

clinics.

4) It is not clear to what extent and for whom post-discharge home visits are a necessary

component of care transitions.

5) The vast majority of the care transitions literature has been hospital-focused, with very

little literature examining the role of primary care teams during the transitions of care.

There is a growing literature examining the effects of medical home interventions, most

of which include cross-site care coordination activities; however, the characteristics of

successful care transitions within the medical home context have not been well explored.

6) Many interventions that have demonstrated a reduction in readmission rates have

included patients at high risk for rehospitalization because of underlying comorbidities

such as CHF and/or because of additional factors such as prior utilization.

7) Interventions designed to address the needs of patients with complex, chronic medical

illness have been the best studied. It is unclear whether the success of some interventions

studied in these patient populations reflects the content expertise intervention personnel

might develop in working with specific patient populations, the higher baseline risk of

poor outcomes among these patients, or sensitivity of chronic medical illness to

transitional care improvements. However, there are many notable exceptions even among

patients with chronic medical illness – for example, we found little evidence of benefit in

COPD populations, though many transitional care components were missing from these

14
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

studies. There is little good-quality transitional care literature in mental health or surgical 

populations. 

8) Reviews that assessed the association between timing of publication and outcome effects,

suggest that many of the interventions demonstrating benefit were conducted more than a

decade ago.

9) In order to allow for better collation of results from trials, development of a standard

taxonomy is needed. This taxonomy should include both population descriptors as well as

intervention descriptors.

POLICY IMPLICATIONS

Understand the spectrum of care transitions activities and diagnose systems 

gaps

There are many potential steps in the care transition that, if not sufficiently addressed, could 

degrade the quality of the care transition. Focusing on just one of these steps – like medication 

reconciliation – alone is unlikely to yield big changes for a population of patients. The pathways 

to readmission are likely many, as suggested both by the inability to accurately anticipate which 

patients will be readmitted,36 and by case review studies characterizing underlying factors 

contributing to preventable readmissions.30 As discussed above, one of the recurring themes in 

the literature is that interventions which account for more aspects of the care transition and 

bridge in- and outpatient sites of care tend to be more successful. 

The problems with recommending that a specific intervention be broadly implemented across 

VA sites include both the lack of evidence supporting such a recommendation and the likelihood 

that the transitional care gaps are not the same in all VAs, nor for all populations of patients 

treated at VAs. Moreover, we found at least 2 large reviews which showed that more recently 

published studies were less likely to have shown an improvement in outcomes, suggesting a need 

to think critically about broadly implementing resource-intensive interventions in the current 

health system context.18,22 

Rather, we propose institutions use a standardized process for assessing the current state of 

transitional care. As part of this review, we developed a transitional care map (Appendix C, 

Figure 2), which diagrams the basic steps that should be considered when targeting areas for 

improvement. The elements on this map were identified through several means: 1) activities that 

have consistently been part of successful transitional care interventions, 2) elements that have 

been part of prior consensus statements, and 3) consensus among our own research team. Ideally, 

the map should be part of collaborative discussions between hospital and outpatient 

administrators and clinicians. 

It is important to adapt the map to different patient populations. For instance, existing transitional 

care processes and gaps are likely to be quite different for patients who are established in a VA 

PACT team and those who do not regularly receive primary care at a VA. It is likely not feasible 

for each institution to examine its transitional care processes for all patient populations served. 

Rather, institutions may choose to focus on particular patient populations experiencing poor 

outcomes (such as high readmission rates), or for whom providers perceive substantial gaps in 

transitional care. 

15
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

The map is a menu of many elements that have been part of successful interventions and some 

(such as outpatient to inpatient communication at the transition into the hospital) that have not 

been adequately studied but in the group’s opinion represent an important opportunity for quality 

improvement investigation. The map has not been tested empirically and its steps are not 

necessarily meant to apply to all patients. Rather, it is meant to be used to assess systemic gaps 

and opportunities for improvement. For instance, we do not know whether and when in-person. 

post-discharge follow-up is needed for all patients, but the means to systematically and easily 

secure follow-up proactively for subsets of patients who do require follow-up should be in place. 

The map is only meant to serve as a guide for discussing current processes of care and gaps in 

care. It is important that stakeholders include representatives from across the care continuum and 

perhaps patient representatives as well. One of the purposes of such discussions is to define a 

shared understanding of accountability for various aspects of the transitional care map. For 

example, inpatient and outpatient providers need to understand who is responsible for following 

tests that are outstanding at the time of discharge. A review of quality improvement methodology 

is beyond the scope of this review, but there are activities such as process mapping that could be 

used to operationalize use of this map.37 

We anticipate this process would be useful for all institutions regardless of current performance 

on measures such as readmission rates both because such outcomes may be an imperfect measure 

of transitional care quality,

38,39 and because an institution may still identify significant residual 

gaps for particular patient populations even if it has been not been identified globally as a poor 

performer. 

Care transitions and PACT

The value of investing in new transitional care personnel relative to harnessing the potential 

value of existing infrastructure and personnel is unclear. The pioneering care transitions 

interventions which had demonstrated reductions in readmissions had largely been patient-level 

interventions that predated widespread adoption of the medical home model of care, and were 

not extensively tested in integrated health systems.

2,11 These interventions were largely 

constructed around a nurse (the “transitional care nurse”) or nurse practitioner dedicated to key 

activities to support better transitional care, such as self-management education, communication, 

information transfer, and follow-up care. 

The literature to date has not fully explored care transitions implementation within the context of 

integrated systems and the medical home model. It is not clear that introducing new roles – such 

as the transitional care nurse – within VA is a requisite step to improving care transitions. It is 

important to acknowledge existing systems innovations which may already be accomplishing 

some of the work done in earlier transitional care interventions. For instance, with some reengineering of the process, the PACT nurse care manager could serve as a point of contact 

during the peri-discharge period. Home-based primary care (HBPC), which is already widely 

used throughout VHA and is associated with a lower risk of hospitalization among higher-risk 

Veterans, could expand its role and serve as a point of continuity during the hospital-to-home 

transition.40 Finally, many larger VAs have structures in place, such as heart failure specialty 

clinics, that could identify patients during an admission and arrange close follow-up. 

16
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Reach-in, reach-out

The vast majority of the transitional care literature to date is hospital-centered. This is likely, at 

least in part, because the overwhelming focus of national policy efforts has been on reducing 

readmissions, and hospitals have been the entities at risk in financial penalization and public 

reporting initiatives. Consequently, most of the intervention literature examines models of care 

that essentially extend hospital services beyond hospital walls. However, it is possible that a 

“reach-in” model of transitions in which PACT personnel engage with patients and inpatient 

providers and take the “hand-off” prior to discharge would work in the VA PACT setting. 

Additionally, the PACT model may represent an opportunity to explore improvements in 

processes of care as patients transition into the hospital. 

On the other hand, the more traditional transitional care models in which hospital-based 

personnel connect with inpatients and then follow through with them after discharge may be the 

right approach for hospitalized Veterans who are either not part of a PACT team, or who 

typically receive care at a different VA institution. 

Consider targeting high-risk populations

Given resource considerations and the lack of strong evidence suggesting benefit of transitional 

care programs across broad populations, it may make most sense to target more resourceintensive aspects of transitional care to higher-risk populations. There are several ways to do this. 

One would be to focus on specific patient populations who are generally at higher risk of poor 

outcomes, such as older patients and CHF patients. Another would be a referral-based system in 

which the clinical team uses its assessment of patient need to determine which patients to refer 

on to more intensive transitional care management. Finally, risk assessment using a formal risk 

scoring tool is yet another approach to identifying high-risk patients. 

It is important to distinguish risk assessment from needs assessment. Risk assessment, as we are 

defining it, simply means assessing the probability that a patient with a given set of 

characteristics will experience a given outcome (often readmissions in this context). Needs 

assessment, on the other hand, refers to a patient’s specific needs and can help inform the 

tailoring of interventions. We consider needs assessment to be an important step for all patients 

and one that necessarily precedes anticipatory discharge planning. Indeed, as discussed in the 

results section, there is good evidence that individually tailored discharge planning can help 

improve outcomes, especially in medical inpatients.21 

The role of risk assessment tools is less clear. Many readmission risk prediction models have 

been tested and they have been, at best, only moderately accurate.36 Nevertheless, even models 

with only modest accuracy may be helpful. We are aware of at least one recent study not 

included in the reviews that successfully used an EMR-based risk prediction tool to identify CHF 

patients for inclusion in an intensive transitional care intervention.41 In addition, there may be 

some utility in using models to identify low-risk patients for whom intervention would not be 

necessary.42,43

The incremental benefits of using a formal risk prediction tool compared to clinician gestalt are 

unclear. The choice may depend on the intended use. Risk prediction models may be useful 

triage tools when trying to apply scarce resources to a large population of patients. For example, 

some health systems have used risk prediction scores as a way to prioritize patients for post17
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

discharge telephone calls. Clinician referral may make more sense when considering patients for 

interventions – such as hospital-at-home programs or HBPC – that reach a smaller segment of 

the population and may need to be more nuanced in understanding patient needs and 

appropriateness of referral. 

If a risk assessment tool is implemented in VA, it is important to consider factors such as model 

complexity, impact on workflow, and application to the population under consideration before 

broad adoption. Very simple models may perform similarly to more complex models and may be 

readily implemented – for example, one health system is using a single risk factor (2 or more 

unplanned admissions in the last year) to identify patients.44 Finally, there is no compelling 

reason that VA needs to consider only readmission risk prediction models. The CAN score was 

developed and validated in VA populations and has good ability to predict future hospital 

admissions or mortality.

45 The incorporation of such a model into the transitional care context is 

another approach that could be considered, but should be studied further. 

Measure outcomes beyond 30 day readmissions

Although poor-quality care transitions can negatively impact patients’ experience of care and 

patient safety,

1-6 hospital readmissions have been the major focus of transitional care literature 

and policy discussions. While reduction in preventable readmissions is a laudable goal, there are 

many uncertainties with this outcome metric including its reliability, its relationship to care 

quality and mortality, and the proportion of readmissions that are ultimately preventable.38,46-48

There are other utilization measures which are often measured, but receive less attention. 

Emergency room utilization (especially visits that do not lead to a hospitalization) would be 

useful to examine in the immediate post-discharge period, especially within the context of the 

medical home, since theoretically some of these may be sensitive to improvements in peridischarge care coordination. The timing of the readmissions metric likely should differ according 

to the group seeking to use the information to guide quality improvement. For instance, 7 day 

readmissions, which may be more reflective of hospital care and discharge planning, might be 

more relevant to VA hospitals while longer-term readmissions (and total admission rates) might 

be of more relevance to PACT teams. 

Care transitions interventions may improve patient-perceived transitional care quality while 

having little impact on high-cost utilization.

49 Nevertheless, improving patient experience of care 

may be, in and of itself, a substantive rationale for transitional care improvements. Transitions 

measures such as the Care Transitions Measure (CTM) which examine patient experience and 

their preparedness should be examined.4

 

Finally, care transitions also have the potential to impact patient safety. The small portion of the 

transitions literature that has examined patient safety outcomes has mainly focused on 

medicational reconciliation interventions and adverse drug event outcomes. Other outcomes such 

as falls, iatrogenic complications, delayed test follow-up, and missed diagnoses have not been 

adequately examined. While such outcomes are difficult to assess on a large scale, systematic 

chart review approaches such as the Global Trigger Tool could be adapted for use in the care 

transitions context.50 

18
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Implementation considerations

It is probably important to think of transitional care improvements at both the patient and system 

level. Implementing a transitional care program – for example, the Care Transitions Intervention 

or Project RED – without an explicit systems-learning component could be a missed opportunity 

to improve sustainability, breadth, and efficiency of systematic transitional care improvements. 

In many VAs, there may already be personnel and structure poised to identify transitional care 

gaps and to work on systems improvements to address those gaps. For instance, multidisciplinary 

inpatient rounds involving medical providers, nursing staff, social workers, physical therapists, 

and nutritionists could be used as a means for anticipatory discharge planning. It is likely that 

such multidisciplinary discussion of patient needs will reveal larger systems gaps. Each VA 

needs the means to not only identify these gaps, but also to feed back the information to local 

and regional leaders who may be able to effect change. It might be useful to designate an 

individual or individuals at each institution who could be empowered to gather data about gaps 

from multidisciplinary team meetings and then report the information to the appropriate 

leadership. 

Quality improvement efforts to improve cross-site communication should explicitly incorporate 

input from in- and outpatient providers and staff. As an example, a group of hospitalists at our 

own hospital has taken the initiative to visit area community-based outpatient clinics (CBOCs)

and conduct semi-structured interviews to better understand primary care provider views about 

improving the structure, content, and timing of discharge summaries. They’ve found differing 

views among primary care providers about means and timing of admission notification, and the 

logistics of orchestrating “warm hand-offs”. 

Dissemination of needs assessment tools could be used to guide multidisciplinary discharge 

planning meetings and craft individually-tailored discharge plans. VA should consider piloting 

the incorporation of these brief assessments and plans into cross-site communication tools such 

as the post-discharge telephone call template and/or the discharge summary. 

Of note, it is important to anticipate some of the potential limitations of using non-VA services, 

such as community home nursing agencies, to accomplish care transitions since their means of 

communication with inpatient and outpatient VA providers (given their lack of access to the 

EMR) is limited and may introduce further discontinuities in care. 

Critically assess the current system of post-discharge telephone calls 

There is little evidence to support the current VA practice of conducting one-time post-discharge 

telephone calls in broad, unselected groups of recently discharged patients. We found little 

evidence from published systematic reviews that simple post-discharge telephone calls improve 

outcomes. However, for high-risk patients with complex chronic illness and high selfmanagement burden, periodic post-discharge contact with trained nurses may be useful. 

Structured telephone support interventions conducted by trained nurses have been associated 

with lower rates of readmissions over the long-term in CHF patients. In these populations such 

interventions may be a useful adjunct, and may be a more practical means of reaching larger 

numbers of VA patients who may be more geographically dispersed than home visit-based 

interventions. 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Of note, the C-Trac intervention study, which was conducted in VA, was more recently 

published and suggested a telephone-based intervention with components bridging in- and 

outpatient care can improve outcomes.51 However, there are important differences between this 

study and the current post-discharge call system. In the C-Trac study, calls were delivered by a 

nurse care manager who visited with patients in the hospital, rounded with the inpatient teams, 

provided patients with call times and a list of red flags, and communicated findings to the 

primary care team. The intervention was perceived as useful by patients, and was associated with 

an 11% absolute reduction in readmission rates after the intervention was introduced. The 

intervention included only high-risk patients as defined by the presence of cognitive impairment 

and/or older age with other comorbidities and prior utilization. Indeed, the baseline readmission 

rate of this population was quite high at 34%, which is substantially higher than 30 day 

readmission rates in older VA and non-VA populations with serious chronic illness.9,52 

Broad application of post-discharge calls may still prove useful even absent clear evidence that 

they reduce utilization. It is possible that such calls are viewed favorably by patients and are a 

useful mechanism for PACT teams to prioritize follow-up care. It is also possible that the 

resource use issues are relatively small since the calls are made by PACT nurses who, at any one 

time, may have relatively few post-discharge calls for a panel of patients. These issues need to be 

explored further in future work. 

Finally, because post-discharge calls have become a major vehicle for transitional care in VA, it 

is important to consider telephone access issues. A sizable minority of patients are unreachable 

after discharge by phone (unpublished data from our own VISN). A given institution should look 

at its own post-discharge call data, assess what proportion of patients are reached, and identify 

reasons why some patients are unreachable. It is likely that, due to socioeconomic circumstances, 

some patients simply do not have access to reliable phone service. It would be important to have 

a system in place, then, to identify these patients prior to discharge and to have all necessary 

follow-up appointments secured and communicated to these patients prior to discharge. 

FUTURE RESEARCH AND QUALITY IMPROVEMENT WORK

In general, there is an overarching need for better evidence to guide selection and 

implementation of complex, multicomponent transitional care interventions in different settings. 

One of the major weaknesses of the transitional care literature is the marked variation in 

intervention definitions, timing of outcome follow-up, and descriptions of interventions and 

usual care. As the VHA conducts more research in this field, use of taxonomies (such as the ones 

described above) to guide study design and description may help standardize reporting. Recently, 

a large Patient Centered Outcomes Research Institute (PCORI) grant was awarded to better 

clarify which transitional care intervention components work, for whom, and in which settings 

based on current experience with care transitions implementation across the country. This should 

help fill in many of the literature gaps we’ve identified. In addition to this work, there are a 

number of more specific areas of investigation that would be relevant to the VHA: 

• Readmissions in mental health care populations are very high in the VHA. There is an

urgent need to better understand mental health patients’ experience as they transition

across setting, and to identify the facilitators and barriers to care transitions in this

population. Similar work should be done in surgical populations.

20
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

• The VHA has an opportunity to think more broadly about the effects of care transitions

beyond hospital readmissions. Patient surveys and qualitative work would be helpful in

better understanding the types of outcomes that matter to patients.

• Adapt transitional care continuous quality improvement methods used by other initiatives

for the VHA setting and populations, incorporating input from personnel across care

settings and integrated with local and regional leadership.

• Even within integrated health systems like VHA, there has been relatively little

examination of the communication between outpatient and inpatient care teams. There is

a need to better understand communication preferences, opportunities, and priorities from

both perspectives. Additionally, more work needs to be done to examine ways in which

communication from the outpatient care teams to the inpatient care teams early on during

a hospital admission could ease subsequent discharge planning (ie, through

communication of care plans, end-of-life discussions, understanding of preference

sensitive decisions).

• There are a number of comparative studies which would be helpful:

o contrasting approaches to transitional care in VA patients with and without a primary

VA-based medical home;

o comparison of home visit-based and telephone-based interventions;

o comparison of unselected and risk-prioritized approaches to post-discharge calls;

o comparison of the use of electronic risk-scoring tools, disease- or age-based criteria,

and clinician gestalt to identify high-risk patients for intensive transitional care

management interventions; and

o evaluation of changes in usual care before and after 2002 to help interpret

effectiveness of studies when compared to usual care

LIMITATIONS

Our review has a number of important limitations. Our approach to reviewing and summarizing 

the literature was necessarily broad rather than deep. There are many nuances in the results, 

internal validity, and generalizability of studies included within these reviews that are not 

represented in our overview. It was difficult to use established criteria to formally rate the 

strength of evidence for each of our conclusions, and few of the included reviews reported 

strength of evidence ratings. As we note in the results, our assessment of the common themes 

across the different reviews is likely best viewed as being based on low-strength evidence, given 

the indirect comparisons and the many different factors that varied among the included studies. 

There was heterogeneity in the outcome timings, making direct comparisons difficult. 

Interventions that improved short-term readmission may not have had lasting effects, whereas 

interventions that seemed ineffective in the short term may have longer term benefit. We only 

included reviews that included readmissions as an outcome as a way to feasibly scope the review 

and because we suspected that most interventions focused on the hospital to home transition 

would report this as an outcome. It is certainly possible that there are interventions that span care 

settings and effect care transitions that focus exclusively on other outcomes (eg, there is a body 

of literature focused on smoking cessation around the time of discharge).53 Furthermore, there 

are many outpatient-based interventions which are designed to affect emergency room and 

21
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

hospital utilization that are not captured in our review, but may nevertheless be important to 

understanding the role of care coordination in the context of the medical home. 

We did not systematically update the included reviews’ searches and, therefore, there are 

undoubtedly more recent studies that have been published that are not represented here, though 

we are not aware of newer studies that would substantively change our summary of findings and 

policy recommendations. Our recommendations are, in part, based on the evidence but also 

incorporate our own subjective assessment of the practical implications of the evidence (or lack 

thereof) and undoubtedly reflect our own clinical, research, and policy experience. 

CONCLUSIONS

The literature includes many different types of interventions, studied in varied populations and 

clinical settings, and implemented in different ways, but there is no commonly used taxonomy 

describing the various factors. Furthermore, there is very little comparative effectiveness data. It 

is, therefore, very difficult to identify specific intervention components and characteristics that 

are necessary for successful care transitions. In general, successful interventions are more 

comprehensive, touch on more aspects of the care transition, extend beyond the hospital stay, 

and are flexible enough to respond to individual patient needs. Transitional care interventions 

have not been well studied within integrated health systems and within the medical home 

context. Future work should focus on how best to incorporate outpatient teams into transitional 

care improvement processes. 

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Transitions of Care from Hospital to Home Evidence-based Synthesis Program

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quality suggest the need for added metrics. Health Affairs. 2013;32(6):1083-1091.

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Journal of the American Medical Association. 2011;306(16):1796-1797.

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of Ambulatory Care–Sensitive Condition Hospitalization Among Older Veterans With

Diabetes Mellitus. JAMA Internal Medicine. 2014;174(11):1796-1803.

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reduce heart failure readmissions: a prospective, controlled study. BMJ Quality & Safety.

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screening on the cost-effectiveness of case management programs. The Gerontologist.

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electronic health record to automatically identify patients at risk for 30‐day readmission.

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Journal of Medicine. 2012;366(15):1366-1369.

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readmission rates. Journal of Evaluation in Clinical Practice. 2012;18(6):1211-1218.

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.

49. Englander H, Michaels L, Chan B, Kansagara D. The Care Transitions Innovation (CTraIn) for socioeconomically disadvantaged adults: results of a cluster randomized

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hospitals may be ten times greater than previously measured. Health Affairs.

2011;30(4):581-589.

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Affairs. 2012;31(12):2659-2668.

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smoking cessation among hospitalized adults: a randomized clinical trial. JAMA : the

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programmes for patients with incurable cancer on their quality of life and time spent in

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psychiatric readmissions in adults: systematic review. The British Journal of Psychiatry:

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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 metaanalysis. Family Practice. 2013;30(3):266-275.

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

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ambulatory complex patients in general health care: a systematic review. Journal of

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61. Chiu WK, Newcomer R. A systematic review of nurse-assisted case management to

improve hospital discharge transition outcomes for the elderly. Professional Case

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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.

63. Ho PM, Luther SA, Masoudi FA, et al. Inpatient and follow-up cardiology care and

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access to primary care for patients with congestive heart failure. Veterans Affairs

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prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled

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70. Cummings JEB HS, Weaver FM, Manheim LM, Conrad KJ, Nash K, et al. Costeffectiveness of Veterans Administration hospital-based home care. A randomized

clinical trial. Archives of Internal Medicine. 1990;150:1274-1280.

28
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

APPENDIX A. TABLES

Table 1. Characteristics and Key Findings of Systematic Reviews of Care Transitions, by Patient Population

Patient 

condition;

Systematic 

review;

Search dates

N controlled trials

(total N studies)

Sample 

characteristics;

N total from RCTs

(Tx + control)

Summary estimate for

readmission risk (95% CI)

Summary estimate for 

mortality (95% CI) Quality measures

Acute MI/ Acute 

Coronary 

Syndrome

Auer, 200834

1966-2007

16 controlled trials, 

including 

14 RCTs

(26 studies total)

Hospitalized for ACS 

including unstable 

angina, NSTEMI, 

STEMI

N=2467 from trials, 

including N=1910 

from RCTs

6-12 months: 0.96 (0.79-1.17) All causes: 0.94 (0.63-1.40)

All causes at 1 year: 0.94 

(0.63-1.44)

Study quality for RCT assessed using 

modified Jadad score 

3 (lowest ROB category): n=8

2: n=5

1 (highest ROB category): n=3

Before-after designs: n=12 (no formal 

ROB assessment)

Cancer

Smeenk, 199854

1985-1997

5 RCTs

(9 studies total)

Cancer

N=4249

Range of ratios for 

readmission (%) in 

intervention

group/control group: 0.62 to 

1.12

Combined estimate NR.

Timing of readmission 

assessment NR.

NR Weighted methodological quality score 

(0-100 max): 

48: n=1

50: n=1

56: n=1

61: n=1

63: n=1

64: n=2

68: n=1

All considered moderate quality

CHF

Feltner, 201419

1990-2013

47 RCTs 

(47 studies total)

Moderate-to-severe 

HF; 

mean age of 70

N=8693

Combined RR (95% CI) by 

intervention type; results from 

single studies per intervention 

type not included below:

Home-visiting program, 3-6 

months: 0.75 (0.66-0.86)

Structured telephone support, 

3-6 months: 0.92 (0.77-1.10)

Telemonitoring, 3-6 months: 

1.11 (0.87-1.42)

Clinic-based (MDS-HF), 6 

months: 0.70 (0.55-0.89)

Combined RR (95% CI) by 

intervention type; results 

from single studies per 

intervention type not 

included below:

Home-visiting program, 3-6 

months: 0.77 (0.60-0.996)

Structured telephone 

support, 3.6 months: 0.69 

(0.51-0.92)

Clinic-based (MDS-HF) 6 

months: 0.56 (0.34-0.92)

AHRQ ROB for trials (high, medium, 

low, unclear)

Low ROB: n=6

Medium ROB: n=27

High ROB: n=9

Unclear ROB: n=5

29
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Patient 

condition;

Systematic 

review;

Search dates

N controlled trials

(total N studies)

Sample 

characteristics;

N total from RCTs

(Tx + control)

Summary estimate for

readmission risk (95% CI)

Summary estimate for 

mortality (95% CI) Quality measures

COPD

Prieto-Centurion, 

201424

1966-2013

5 RCTs

(5 studies total)

Patients hospitalized 

for COPD within the 

previous 12 month.

N=1393

2 studies found reduced 12-

month readmissions (mean 

number of hospitalizations per 

patient, 1.0 vs 1.8;P = 0.01; 

percent hospitalized, 45 vs

67%;P= 0.028)

3 studies found no significant 

change in 6 or 12-month 

readmissions. 

4 of 5 studies: no difference

1 study: increased 12-month 

mortality (17 vs 7%, 

p=0.003)

EPOC criteria (# domains with low 

ROB: 1-7 max)

6: n=4

5: n=1

General/

unselected

Leppin, 201418

1990-2013

42 RCTs

(42 studies total)

N=17273 30 days: 0.82 (0.73-0.91) NR EPOC ROB (high, low, unclear)

“Most studies were at overall low risk 

of bias. The most common 

methodological limitation of these trials 

was the lack of a reliable method for 

dealing with missing data.” 8/42 

studies were rated as low ROB in all 

categories; all others were rated as 

high or unclear ROB in one or more 

categories.

Mental Health 

Vigod, 201355

Database 

inception 

through 2012 

13 controlled trials, 

including 

8 RCTs

(15 studies total)

Admitted to the 

hospital for mental 

health inpatient care

N=2880 (Controlled 

trials)

N=1007 (RCTs)

Range among studies in % of 

patients readmitted, 

intervention group vs control:

3 month: 7-23 vs 13-36

6-24 month: 0-63% vs 4-69% 

NR EPOC criteria (# domains with low 

ROB: 1-9 max)

8: n=1

7: n=1

6: n=1

5: n=4

4: n=3

3: n=3

Most included studies had small 

sample sizes, high dropout rates, 

and/or did not account for baseline 

differences between groups on key 

prognostic factors.

30
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Patient 

condition;

Systematic 

review;

Search dates

N controlled trials

(total N studies)

Sample 

characteristics;

N total from RCTs

(Tx + control)

Summary estimate for

readmission risk (95% CI)

Summary estimate for 

mortality (95% CI) Quality measures

Stroke

Prvu-Bettger, 

201220

2000-2012

24 RCTs stroke

8 RCTs MI

(44 studies total: 

27 stroke, 

17 MI)

hospitalized for 

stroke or acute 

coronary syndromes

N=4307 stroke

N=1062 MI

Insufficient evidence for most 

intervention subtypes in both 

stroke and MI. Moderate 

strength evidence that 

hospital-initiated support did 

not reduce readmissions in 

stroke patients. Timing of 

readmission assessment NR.

Low strength evidence in MI 

patients: reduced 3 month 

mortality (1 study), reduced 

12 month mortality (2 

studies) 

AHRQ (Good, Fair, Poor Quality)

Good: n=10

Fair: n= 42

Poor: n=10

Strength of evidence insufficient for all 

intervention/population subgroups 

except as noted. 

Abbreviations: ACS = acute coronary syndrome; AHRQ = Agency for Healthcare Research & Quality; CHF = congestive heart failure; CI = confidence interval; COPD = chronic 

obstructive pulmonary disease; EPOC = Cochrane Effective Practice and Organisation of Care Group; HF = heart failure; MDS-HF = multidisciplinary heart failure; MI = 

myocardial infarction; N = population/study sample size; NR = not reported; NSTEMI = non-ST-segment elevation myocardial infarction; RCTs = randomized controlled trials; 

ROB = risk of bias; STEMI = ST-segment elevation myocardial infarction; Tx = treatment; vs = versus

31
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Table 2. Characteristics and Key Findings of Systematic Reviews of Care Transitions, by Intervention Type

Key process;

Systematic 

review;

Search dates

N controlled 

trials

(total N studies)

Sample characteristics;

N total from RCTs 

(Tx + control)

Summary estimate for 

readmission risk 

(95% CI)

Summary estimate for 

mortality (95% CI) Quality measures

Geriatric Case 

Management

Huntley, 201356

1950-2010

11 RCTs

(11 studies total)

Patients aged 65+ who 

were discharged from 

acute care hospitals (ED 

included) or were 

community dwelling

N=4318

0.71 (0.49-1.03) Combined estimate NR. 

Mortality (5 studies) was not 

significantly different based 

on case management.

Cochrane ROB

“Risk of bias was generally low”. 

Most studies had low or unclear 

ROB in all categories except one 

study which had high ROB in 3 

categories. 

Geriatric Case 

Assessment

Ellis, 201135

1966-2010

22 RCTs

(22 studies total)

Adults aged 65 years or 

older who were admitted 

to the hospital. N=10,315

No difference between 

groups, N=3822. 

OR 1.03 (0.89-1.18)

Death or functional decline, 

combined outcome: 0.76 

(0.64 to 0.90, P=0.001) 

based on data from 5 RCTs, 

N= 2622

Cochrane ROB 

“The studies identified were 

heterogeneous in quality. All used 

some method of individual patient 

randomization, though reporting of 

key issues such as allocation 

concealment varied. Outcome 

assessment was seldom blinded 

[though] this is less of an issue for 

hard outcomes such as death or 

institutionalization”. Some trials 

noted attrition for functional or 

cognitive outcomes.”

Discharge 

planning

Shepperd, 201321

1946-2012

24 RCTs

(24 studies total)

Mostly older medical 

patients, but some trials 

included a mix of medical 

and surgical conditions. 

Psychiatric patients were 

included as well. 

N=8,098

Within 3 months of 

discharge: 

0.82 (0.73-0.92) for older 

patients with a medical 

condition. No difference 

was found when mixed 

medical and surgical 

populations were included. 

At 6-9 months: 0.99 (0.78-

1.25)

Cochrane ROB, 

Low ROB: n=9

Medium ROB: n=9

High ROB: n=5

Unclear ROB: n=1

ERAS/Fast Track

Kagedan, 201457

2000-2013

0 trials or RCTs

(10 studies total)

After pancreatic surgery

N=0 (no RCTs)

Range among studies in % 

of patients readmitted, 

ERAS vs UC: 

(3.5-15) vs (0-25)

Range (% of patients), 

ERAS vs UC: (0-4) vs (0-3)

32

GRADE (Low; Moderate; High)

”No high-quality studies were 

identified. Cohort studies comparing 

multiple groups were labelled as 

being of moderate quality. Singlegroup prospective studies were 

graded as low quality.” Moderate 

quality: n=7

Low quality: n=3
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Key process;

Systematic 

review;

Search dates

N controlled 

trials

(total N studies)

Sample characteristics;

N total from RCTs 

(Tx + control)

Summary estimate for 

readmission risk 

(95% CI)

Summary estimate for 

mortality (95% CI) Quality measures

Hospital at home

Caplan, 201222

Database 

inception through 

2012 

61 RCTs

(61 studies total)

N=6992 0.75 (0.59-0.95) 0.81 (0.69-0.95) EPOC criteria

Quality ratings not reported; “Almost 

all studies were not blinded. 

However, many studies used blinded 

initial assessments before 

randomisation. Some outcome 

assessment was blinded.”

Medication 

reconciliation

Kwan, 201323

1980-2012

5 RCTs

(18 studies total)

N=1075 ER visits and 

hospitalizations within 30 

days of discharge in 3 

RCTs, HR 0.77 (95% CI, 

0.63-0.95)

NR Cochrane ROB 

Low ROB: n=5 RCTs 

PCMH

Jackson, 201358

Database 

inception through 

June 2012

9 RCTs

(19 studies total)

Unselected population

N=54465

0.96 (0.84-1.10) NR AHRQ (Good, Fair, Poor Quality). All 

but one study were rated as being 

good or fair quality.

Telemonitoring 

and structured 

telephone support

Pandor, 201326

1999-2011

21 RCTs

(21 studies total)

Heart failure

N=6317

Median HR (credible 

interval, 2.5%-97.5%) vs

UC. 

All-cause:

STS HH: 0.97 (0.70-1.31)

TM office hours 

(transmitted data reviewed 

by medical staff during 

office hours): 0.75 (0.49-

1.10) 

HF-related:

STS HH: 0.77 (0.62-0.96)

TM office hours: 0.95 (0.70-

1.34)

Median HR (credible interval, 

2.5%-97.5%) vs UC: 

STS HH vs UC: 0.77 (0.55-

1.08)

TM office hours vs UC: 0.76 

(0.49-1.18)

Study quality not reported 

individually; “The methodological 

quality of the 21 included studies 

varied widely and reporting was 

generally poor on random sequence 

generation, allocation concealment, 

blinding of outcome assessment, 

definition and confirmation of HF 

diagnosis, and

intention-to-treat analysis.”

33
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Key process;

Systematic 

review;

Search dates

N controlled 

trials

(total N studies)

Sample characteristics;

N total from RCTs 

(Tx + control)

Summary estimate for 

readmission risk 

(95% CI)

Summary estimate for 

mortality (95% CI) Quality measures

Telephone followup, primary-care 

based

Crocker 201229

1948-2011

3 RCTs

(3 studies total)

Unselected population

N=1765

Combined estimate NR. 

None of the 3 RCTs 

reported a statistically 

significant impact of 

telephone follow-up on 

readmission or ER visits.

NR Study quality not reported 

individually: assessed sequence 

generation, allocation concealment, 

blinding, follow-up and intent to treat 

analysis, and publication bias. Most 

studies were high or unclear ROB 

based on poor reporting of sequence 

generation, allocation concealment; 

lack of blinding; and lack of 

information about attrition. 

Telephone followup, hospitalbased

Mistiaen, 200628

Database 

inception through 

July 2003

13 RCTs

(33 studies total)

Unselected population 

with cardiac and surgical 

subgroup analyses

N=5110

Cardiac (3 RCTs, N=616):

0.75 (0.41-1.36)

Surgical (4 RCTs, N=460):

0.65 (0.28-1.55)

NR Cochrane ROB 

Medium ROB: n=7

High ROB: n=26

Abbreviations: AHRQ = Agency for Healthcare Research & Quality; CI = confidence interval; ED = emergency department; EPOC = Cochrane Effective Practice and Organisation 

of Care Group; ER = emergency room; ERAS = enhanced recovery after surgery; GRADE = grading of recommendations assessment, development and evaluation; HR = hazard 

ratio; N = population/study sample size; NR = not reported; OR = odds ratio; RCTs = randomized controlled trials; ROB = risk of bias; STS HH = structured telephone support 

delivered by human-to-human contact; TM = telemonitoring; Tx = treatment; UC = usual care; vs = versus

34
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Table 3. Clinical Outcomes, Utilization Outcomes, and Implementation Considerations in Systematic Reviews of Care 

Transitions, by Patient Population

Patient 

population

Systematic 

review;

Search dates

Clinical outcomes Other utilization 

outcomes Implementation considerations Limitations/comments

Acute MI/Acute 

Coronary 

Syndrome

Auer, 200834

1966-2007

Re-infarction rates RR 0.51, 

95% CI 0.23 – 1.13 among 

trials) 

Smoking cessation RR 1.29 

(1.02-1.63, I2 = 66%)

NR Interventions that included provider- or 

systems-level components reduced mortality 

(RR 0.77, 95% CI 0.65-0.92) whereas patientlevel interventions did not (RR 0.93, 95% CI 

0.63-1.36). However, many of the studies of 

provider- or systems-level interventions were 

before-after studies. 

Interventions targeting an increase in the use 

of effective medications were associated with 

mortality benefit (RR 0.80, 95% CI 0.68-0.93) 

whereas those not targeting medication use 

were not (RR 0.75, 95% CI 0.39-1.46). 

Substantial statistical and clinical 

heterogeneity among studies. 

Nearly half the included studies were 

before-after studies and these accounted 

for most of the benefit seen [mortality 

clinical trials only RR was 0.96 (0.64-1.44) 

vs 0.77 (0.66-0.9) for before-after designs]

All studies were published 2005 and 

earlier; applicability to current practice is 

uncertain. 

Cancer

Smeenk, 199854

1985-1997

Quality of life outcomes were 

positively associated with 

home care programs in 3 of 7 

studies.

NR Programs that included multidisciplinary team 

meetings and involvement of team members 

during patient home visits was associated with 

favorable outcomes in 3 studies. 

Author notes: The methodological quality of 

the studies was moderate (median score of 

62/100). The main shortcomings were in 

the areas of population homogeneity, study 

design, comparability of groups, handling of 

drop outs, and blinding procedures. 

Furthermore, the findings of failed to show 

a consistent pattern across studies

CHF

Feltner, 201419

1990-2013

NR NR The following types of interventions had no 

effect on mortality: telemonitoring, nurse-led 

clinics, and primarily educational intervention. 

(low SOE)

Evidence was insufficient for primary care 

interventions and cognitive training programs.

Minimal 30 day data.

UC not well defined and quite variable.

Conclusions of this study and the NHS one 

focusing on TM/STS reach different 

conclusions with slightly different study 

inclusion.

35
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Patient 

population

Systematic 

review;

Search dates

Clinical outcomes Other utilization 

outcomes Implementation considerations Limitations/comments

COPD

Prieto-Centurion, 

201424

1966-2013

NR NR Author states: No specific intervention or 

bundle of interventions could be identified as 

effective in reducing the rate of 

rehospitalizations.

Well done systematic review with a focus 

on readmission. Studies that did not have 

readmission as the primary outcome were 

excluded. No studies were found that 

examined 30-day readmission as a primary 

outcome, all used either 6 or 12 months. 

Some studies initiated interventions >28 

days after the patient was discharged. 

Extensive heterogeneity in both the content 

and context of the intervention.

General/unselected

Leppin, 201418

1990-2013

NR NR Characteristics of the intervention such as 

impact on patient workload and the site of 

delivery had no significant effect.

Adjusted for year of publication

Mental Health 

Vigod, 201355

Database inception 

through 2012 

NR NR Study author identified the following as 

effective components within the context of 

multicomponent interventions: pre-discharge 

medication education/reconciliation; postdischarge telephone follow-up, efforts to 

ensure timely follow-up appointments, home 

visits and peer support, bridging components 

of transition manager; and timely 

communication by in-patient staff with an outpatient care or community service provider 

during transition. 

These results are consistent with the 2 

other MH reviews. 

Stroke

Prvu-Bettger, 

201220

2000-2012

No significant differences in 

ADLs (7 studies using the 

Barthel index). 

Insufficient evidence on 

caregiver outcomes 

(inconsistent effects on 

caregiver strain, quality of life 

in 5 studies measuring 

caregiver outcomes)

NR Insufficient evidence of benefit of patient and 

family educational interventions (5 studies), 

community based support (10 studies), and 

chronic disease management 

(2 studies).

Limitations of the studies include sample 

size, heterogeneity of outcome measures, 

lack of definition for the UC group, and fair 

or poor study quality. Authors cite the need 

for definitive taxonomy for the components 

of transitional care services and the 

evaluation of outcome measures.

Abbreviations: ADLs = activities of daily living; CHF = congestive heart failure; CI = confidence interval; COPD = chronic obstructive pulmonary disease; MH = mental health; 

MI = myocardial infarction; NR = not reported; RR = relative risk; SOE = strength of evidence; UC = usual care

36
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Table 4. Clinical Outcomes, Utilization Outcomes, and Implementation Considerations in Systematic Reviews of Care 

Transitions, by Intervention Type

Key process;

Systematic 

review;

Search dates

Clinical outcomes Other utilization outcomes Implementation considerations Limitations/comments

Geriatric Case 

Management

Huntley, 201356

1950-2010

NR ED visits, GP visits, specialist 

clinic/outpatient visits and 

length of stay were not 

improved by case 

management in all but one 

study.

Case management initiated in hospital (2 

RCTs) was associated with decreased 

readmissions; 3 out of 4 RCTs showed no 

difference for case management initiated 

upon discharge; 5 RCTs on case 

management initiated in the community 

showed no significant differences in 

readmissions.

4 other case management 

systematic reviews report 

similar findings: some limited 

examples of positive results, but 

overall non-significant effects.

59-62

Geriatric Case 

Assessment

Ellis, 201135

1966-2010

There was a significant 

reduction in cognitive function (5

trials, 3317 participants, 

standardized mean difference 

0.08, 0.01 to 0.15, P=0.02) 

associated with CGA. There 

were non-significant differences 

for dependence. 

The hospital costs of CGA 

intervention were mixed – 

some trials reported 

decreased cost while others 

reported increased cost. Few 

trials accounted for nursing 

home costs; those that did 

suggested that CGA might be 

associated with overall 

reduced cost. 

The positive impact on living at home was 

seen only in studies of CGA wards and not 

among studies of mobile CGA consultative 

teams (interaction χ

2 = 9.06, p = 0.003). 

There is only evidence supporting CGA 

assessment in setting of geriatric wards, 

and not for consultative teams. The 

authors speculate that specialized wards 

allow nursing and other key personnel to 

develop skills and expertise and foster 

multi-disciplinary team-building, while 

consulting teams might have difficulty in 

influencing health provider behavior. 

Author notes: Trials evaluating 

direct admission from ED all 

have admission criteria related 

to age, whereas trials 

evaluating post-acute care all 

have criteria related to needs 

(with one trial as an exception). 

Author suggests that the 

optimal model of 

comprehensive geriatric 

assessment for hospitals 

includes both acute and postacute models.

37
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Key process;

Systematic 

review;

Search dates

Clinical outcomes Other utilization outcomes Implementation considerations Limitations/comments

Discharge 

Planning

Shepperd, 201321

1946-2012

CHF patients improved on total 

CHFQ score in one trial: mean 

difference 22.1 (20.8), p<0.01; 

whereas, control patients in a 

trial of stroke patients had more 

functional improvement on the 

Barthel score (2 points change 

in tx vs 6 points change in

controls, p<0.01).

QOL outcomes were mixed 

among studies. 

No difference between groups in 

5 trials that reported functional 

status, mental well-being, 

perception of health, selfesteem, and affect.

LOS after medical admission 

was lower with discharge 

planning vs UC: mean 

difference in 10 trials -0.91 

days (95%CI -1.55 to -0.27) in 

10 trials.

LOS after surgery did not 

differ: mean difference in 2 

trials -0.06 days (95%CI -1.23 

to 1.11). 

The point during admission when 

discharge planning may have bearing on 

timely follow-up. Discharge planning was 

implemented varied across studies:

commencing from time admission in 2

trials, 3 days prior to discharge in one 

study. 

Very good review that looked at 

a wide range of trials including 

a diverse group of patients. 

Significant heterogeneity 

existed between trials with 

regards to specific 

interventions. Some 

interventions were not well 

described, making comparisons 

between trials difficult. 

ERAS/Fast Track

Kagedan, 201457

2000-2013

NR. Four studies examined costs 

associated with postoperative 

care following pancreatic 

surgery. Two of these studies 

found a decrease in cost 

following the implementation of 

an ERAS protocol and 2

studies found no significant 

change.

NR This review focused on 

pancreatic surgery, and notes 

that, “Although randomized 

trials and meta-analyses have 

consistently reported an 

advantage to ERAS over 

conventional care, these 

studies have been performed 

predominantly in colorectal 

surgery patients.”

38
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Key process;

Systematic 

review;

Search dates

Clinical outcomes Other utilization outcomes Implementation considerations Limitations/comments

Hospital at home

Caplan, 201222

Database 

inception through 

2012 

No meta-analysis was 

performed for patient or 

caregiver satisfaction because 

varied instruments were used, 

but studies consistently found 

higher satisfaction in HAH 

groups (21/22 studies reporting 

patient satisfaction, 6/8 studies 

reporting CG satisfaction). 

No difference in caregiver 

burden (7 studies, mean 

difference 0.00, 95% CI -0.19 to 

0.19). 

Mean cost difference HAH vs

UC (11 RCTS): -1567.11 (-

2069.53 to -1064.69, p<0.001)

Average cost savings 26.5%. 

32 of 34 studies reporting any 

cost data concluded HAH was 

less expensive.

Mortality, readmission, and cost findings 

were consistent across all subgroups (type 

of hospitalization, degree of admission 

substitutions, average age of patient, and 

year of publication).

Components of HAH programs are not 

described at all; the only criterion seems to 

have been home-based care substitution. 

Specific components of any of 

the HAH intervention are not 

well-described.

Periods of observation for 

mortality and readmissions 

were not defined and likely 

varied significantly. 

“Next best” review has differing 

conclusions: Cochrane review 

from 2009 of HAH to facilitate 

early discharge (as opposed to 

HAH to replace admission) 

found no clear difference in 

mortality in stroke (HR 0.79 

[0.32—1.91]) or mixed elderly 

(HR 10.6 [0.69—1.61]), and 

they found higher readmissions 

among the elderly (HR 1.57 

[1.10—2.24]). They did find 

lower rates of residential care 

and greater satisfaction, with 

cost data mixed.

Medication 

Reconciliation

Kwan, 201323

1980-2012

Fewer adverse drug events 

occurred in 2 studies, 

respectively: 

Tx vs control: 1% vs 11% 

(p=0.01)

RR 0.72 (95% CI 0.52 to 0.99)

NR NR

39
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Key process;

Systematic 

review;

Search dates

Clinical outcomes Other utilization outcomes Implementation considerations Limitations/comments

PCMH

Jackson, 201358

Database 

inception through 

June 2012

One observational study 

reported a higher rate of 

improved HbA1c and LDL 

cholesterol in tx patients.

Another obs. study found no 

difference in composite diabetes 

and CAD outcomes. 

None of the 3 RCTs found 

differences in self-reported 

health status. One observational

study found less functional 

decline with PCMH at 1-year 

follow-up (31% vs 49% of 

patients). 

Three RCTs reporting ED 

utilization found no effect:

combined RR 0.93 (95% CI 

0.72 to 1.20).

NR The components, models, and 

operationalization of PCMH 

varied widely among studies. 

40
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Key process;

Systematic 

review;

Search dates

Clinical outcomes Other utilization outcomes Implementation considerations Limitations/comments

Telemonitoring

Pandor, 201326

1999-2011

Quality of life was significantly 

improved in 3 of 4 studies of 

STS interventions, and 2 of 4 

studies of TM interventions that 

measured and reported it. 

HF-related hospitalizations:

STS HM vs UC: 1.02 (0.70-

1.49)

STS HH vs UC: 0.76 (0.61-

0.94)

TM office hours vs UC: 0.86 

(0.61-1.21).

LOS was reported in 6 studies 

but unaffected in 5 of them 

(shorter in Tsuyuki et al, 

2004).

In the 5 studies that reported it, adherence 

to RM was good (STS 55-84%, TM 81-

98%). Likewise, reported acceptance 

and/or satisfaction rates were high in 5 of 6 

studies. In the sixth, however (Scherr, 

2009), 16/66 patients in the intervention 

group either did not transmit any data or 

requested early termination. 

Since RM cannot affect outcomes unless 

actions are taken based on results of 

monitoring, any successful intervention 

also requires patient 

education/empowerment and advice/timely 

access to care. 

Studied interventions were heterogeneous 

in terms of monitored parameters and HF 

selection criteria, and results were not 

reported in such a way as to permit 

assessment of intervention effect 

modifiers. Thus, uncertainties remain 

around best “active ingredients” of RM 

interventions, suitability of different 

systems, and determinants of patient 

responsiveness. 

Finally, RM is likely to have greater impact 

in systems where UC is suboptimal and 

HF readmission rates are high.

This is limited to HF patients 

and cannot be extrapolated to 

other patient populations.

The authors intended to use 

meta-regression to explain 

heterogeneity in effects 

between studies but could not 

because of limited data on 

study-level covariates. 

Telephone followup, 

Primary-care 

based

Crocker 201229

1948-2011

NR In all 3 included studies, 

primary care contact improved 

with post-discharge telephone 

follow-up. 

2 studies examining ED visits 

showed no effect. 

NR Search may have overlooked 

relevant studies held in other 

databases. 

41
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Key process;

Systematic 

review;

Search dates

Clinical outcomes Other utilization outcomes Implementation considerations Limitations/comments

Telephone followup, Hospital-based

Mistiaen, 200628

Database 

inception through 

July 2003

Anxiety in cardiac surgery 

patients 1 month post-discharge 

was not significantly different. Tx

vs UC, pooled effect from 3 

studies: standardized mean 

difference 

-0.47 (95% CI -1.28 to 0.34)

Depression was not significantly 

different between tx and control 

in 2 studies. 

ED visits in surgery patients 

was not significant. Pooled 

from 2 studies, tx vs control:

RR 1.47 (95% CI 0.85 to 2.53)

NR Most of the included studies 

were poor quality (high ROB) 

and small sample size. The 

authors cite clinical diversity 

and statistical heterogeneity 

among studies as further 

limitations. They note, however, 

that patients valued the TFU 

calls despite no detectable 

benefits in the measured 

empirical outcomes.

Abbreviations: CAD = coronary artery disease; CGA = comprehensive geriatric assessment; CHF = congestive heart failure; CHFQ = chronic heart failure questionnaire; CI = 

confidence interval; ED = emergency department; ERAS = enhanced recovery after surgery; GP = general practice; HAH = hospital at home; HbA1c = glycated hemoglobin A1c; 

HF = heart failure; HR = hazard ratio; LDL = low density lipoprotein; LOS = length of stay; NR = not reported; PCMH = patient-centered medical home; QOL = quality of life; 

RCT = randomized controlled trial; RM = remote monitoring; ROB = risk of bias; RR = relative risk; STS = structured telephone support; STS HM = structured telephone support 

human to machine interface; TFU = telephone follow-up; TM = telemonitoring; Tx = treatment; UC = usual care; vs = versus

42
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Table 5. Studies of Care Transition Interventions Conducted in VA Settings

Study

Design and setting (N)

Years of observation

Patient 

population Intervention Summary of findings

Ho, 200763

Retrospective cohort study 

using data from all VAMCs

(N=4933)

2003-2004

Acute coronary 

syndromes 

including acute 

MI and unstable 

angina

Inpatient and 

follow-up 

cardiology care 

Compared with other levels of cardiology care (inpatient only, outpatient only, and neither inpatient 

nor outpatient), unadjusted all-cause mortality was lower for patients with inpatient and follow-up 

cardiology care (18.8% vs 22.1%, p = 0.009). 

In multivariable analysis adjusting for age, race, site, comorbidities, hospital presentation factors 

(TIMI risk score for STEMI or NSTEMI, left ventricular systolic dysfunction, abnormal serum 

creatinine level), receipt of PCI and/or CABG surgery, discharge medications, and follow-up visit with 

a primary care provider within 60 days after discharge, patients with inpatient and follow-up 

cardiology care remained at lower risk for mortality (HR 0.73, 95% CI 0.62-0.87). 

Oddone, 199964

Multi-site RCT

9 VAMCs (N=443)

Observation period NR

CHF Enhanced 

access to 

primary care

Enhanced access to primary care did not improve quality of life and increased hospital readmissions, 

with an average of 1.5 ±2.0 readmissions per 6 months of follow-up for patients who had enhanced 

access compared with 1.1 ±1.8 for those who received UC (P= 0.02). 

Wakefield, 200865

Single site RCT (N=148)

2002-2006

CHF Home telehealth Readmission at 12 months comparing telephone and videophone groups combined vs control: 59% 

vs 41%; unadjusted OR 0.49 (95% CI 0.24-0.98; p = 0.04) 

Risk of all-cause admission was significantly lower in the intervention group, adjusted for age, mean 

LVEF, NYHA classification, and MLHF instrument proportional hazards model: HR 0.54 (95% CI 

0.33-0.90; p = 0.02)

Mortality did not differ between intervention and control at 3 or 12 months. A Cox proportional 

hazards model adjusting for age, mean LVEF, NYHA classification, and MLHF found no difference in 

mortality at 12 months (HR = 1.04; 95% CI: 0.49, 2.24; p = 0.91). 

Fan, 201266

Multisite RCT

20 VA hospital-based 

outpatient clinics (N=426)

2007-2009

COPD Comprehensive 

care 

management

Trial was stopped early due to excess risk of death in the intervention group (compared with UC; 17 

vs 7%, p = 0.003) At that time, the 1-year cumulative incidence of COPD related hospitalization was 

27% in the intervention group and 24% in the UC group (HR, 1.13 [95% CI, 0.70 to 1.80]; P = 0.62). 

An extensive evaluation by the study authors failed to identify a reason that mortality was higher in 

the intervention group.24 

Fitzgerald, 199467

Single-site RCT (N=668)

1988-1990

General 

medicine/ 

unselected

Telephonebased follow-up 

by nurse case 

managers

No significant differences between intervention and control groups in non-elective readmissions, 

readmission days, or total readmissions.

No significant difference in mortality, Tx vs comparator (%): 10.5 vs 10.4, (p=0.90) 

Average follow-up, Tx vs comparator (months): 12.14 vs 12.23

43
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Study

Design and setting (N)

Years of observation

Patient 

population Intervention Summary of findings

Evans, 199368

Single-site RCT (N=835)

Observation dates NR

High-risk 

patients (riskscreening index 

score* >=3)

Discharge 

planning

Patients receiving early discharge planning were more likely to return home after hospitalization and 

less likely to be readmitted within 9 months. Tx vs control, % of patients:

30-day readmission: 24 vs 35 (p=0.001)

9-month readmission: 55 vs 61 (p=0.08)

Discharged to home: 79 vs 73

Discharged to nursing home: 15 vs 22 (p=0.05 for discharge location)

Deceased at discharge: 2 vs 2 (p=NS)

Deceased at 9 months: 16 vs 16 (p=NS)

At home at 9 months: 62 vs 54

In nursing home at 9 months: 19 vs 26 (p=0.05 for location at 9 months)

Kasprow, 200769

Multi-site implementation 

study with historical controls

8 VAMCs (N=484)

2001-2004

Homeless 

Veterans 

hospitalized for 

mental illness

Critical time 

intervention

community case 

management

with structured 

needs 

assessment

Compared with historical controls, the intervention cohort:

• Had significantly fewer psychiatric problems at 3-, 6-, and 9-month follow-up (p<.001, p<.001, and

p=.005, respectively).

• Spent significantly fewer days in institutional settings at the 6-, 9-, and 12-month follow-up

intervals (p=.01, p=.001, and p=.001, respectively) compared with historical controls.

• Had significantly more days housed at 6-, 9-, and 12-month follow-up (p=.02, p=.001, and p=.001,

respectively).

• Had significantly lower alcohol use than historical controls at 3-, 6-, and 9 month follow-up

(p<.001, p<.001, and p=.001, respectively).

• Had significantly lower drug use at 3-, 6-, and 6-month follow-up (p<.001, p<.001, and p=.04,

respectively).

Weinberger, 199631

Multi-site RCT

9 VAMCs (N=1396)

1992-1994

Inpatients with 

DM, COPD, or 

CHF

Discharge 

planning

In an intensive primary care intervention involving close follow-up by a nurse and PCP from predischarge to 6 months post-discharge, the proportion of patients readmitted within 6 months did not 

significantly differ between intervention and control patients: 49% vs 44% (p=0.06)

44
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Study

Design and setting (N)

Years of observation

Patient 

population Intervention Summary of findings

Cummings, 199070

Single-site RCT (N=419)

1984-1987

Severely 

disabled or 

terminally ill 

patients

HBHC Total VA hospital days did not significantly differ between HBHC and control groups. 

HBHC patients spent a greater proportion of their hospital stay on the intermediate care ward (3.0 

days vs 1.5 days) p<.03) and less time on general care wards (8.5 days vs 12.2 days, p<.04) than 

control group patients.

Total per-patient hospital costs were lower in the HBHC group vs controls ($3000.24 vs $4245.84, 

p=0.03). 

HBHC patients had greater satisfaction with care (0.1 on a 3-point scale, p<.001) than controls, at 1 

month. No significant group differences in satisfaction at 6 months. No significant differences in 

patient morale at either 1 or 6 months.

* Evans RL, Hendricks RD, Lawrence KV, Bishop DS. Factors influencing use of health care resources: A hospital-based risk screening index. Soc Sci Med 1988; 27(9):947.

Abbreviations: CABG = coronary artery bypass graft; CHF = congestive heart failure; CI = confidence interval; COPD = chronic obstructive pulmonary disease; DM = diabetes 

mellitus; HR = hazard ratio; HBHC = hospital-based home care; LVEF = left ventricular ejection fraction; MI = myocardial infarction; MLHF = Minnesota Living with Heart 

Failure; N = population/sample size; NR = not reported; NSTEMI = non-ST-segment elevation myocardial infarction; NYHA = New York Heart Association; OR = odds ratio; 

PCI = percutaneous coronary intervention; PCP = primary care provider; RCT = randomized controlled trial; STEMI = ST-segment elevation myocardial infarction; TIMI = 

Thrombolysis in Myocardial Infarction; UC = usual care; VA = Veterans Affairs; VAMCs = Veterans Affairs Medical Centers

45
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

APPENDIX B. SEARCH STRATEGY 

Concept Search string

recurrence "recurrence"[MeSH Terms] OR "recurrence"[All Fields]

recurrences "recurrence"[MeSH Terms] OR "recurrence"[All Fields] OR "recurrences"[All 

Fields]

hospital-based home 

care

"home care services, hospital-based"[MeSH Terms] OR ("home"[All Fields] AND 

"care"[All Fields] AND "services"[All Fields] AND "hospital-based"[All Fields]) 

OR "hospital-based home care services"[All Fields] OR ("hospital"[All Fields] 

AND "based"[All Fields] AND "home"[All Fields] AND "cares"[All Fields])

eHealth "telemedicine"[MeSH Terms] OR "telemedicine"[All Fields] OR "ehealth"[All 

Fields]

telehealth "telemedicine"[MeSH Terms] OR "telemedicine"[All Fields] OR "telehealth"[All 

Fields]

telemedicine "telemedicine"[MeSH Terms] OR "telemedicine"[All Fields]

continuity "Continuity"[Journal] OR "continuity"[All Fields]

referral

"referral and consultation"[MeSH Terms] OR ("referral"[All Fields] AND 

"consultation"[All Fields]) OR "referral and consultation"[All Fields] OR 

"referral"[All Fields]

discharge "patient discharge"[MeSH Terms] OR ("patient"[All Fields] AND "discharge"[All 

Fields]) OR "patient discharge"[All Fields] OR "discharge"[All Fields]

sub-acute care

"subacute care"[MeSH Terms] OR ("subacute"[All Fields] AND "care"[All Fields]) 

OR "subacute care"[All Fields] OR ("sub"[All Fields] AND "acute"[All Fields] 

AND "care"[All Fields]) OR "sub acute care"[All Fields]

subacute care "subacute care"[MeSH Terms] OR ("subacute"[All Fields] AND "care"[All Fields]) 

OR "subacute care"[All Fields]

cochrane database syst 

rev[ta] "Cochrane Database Syst Rev"[Journal]

acp journal club[ta] "ACP J Club"[Journal]

health technol 

assess[ta] "Health Technol Assess"[Journal] 

evid rep technol assess 

summ[ta] "Evid Rep Technol Assess (Summ)"[Journal] 

evidence-based 

medicine[mh] "evidence-based medicine"[MeSH Terms]

behavior and behavior 

mechanisms[mh] "behavior and behavior mechanisms"[MeSH Terms] 

therapeutics[mh] "therapeutics"[MeSH Terms]

risk[mh] "risk"[MeSH Terms]

death "death"[MeSH Terms] OR "death"[All Fields]

treatment 

outcome[mh] "treatment outcome"[MeSH Terms]

Humans[Mesh] "humans"[MeSH Terms]

adult[MeSH] "adult"[MeSH Terms]

46
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Database: PubMed

Date of search: 5/02/2014

Filters activated: Humans, English, Adult: 19+ years 

User query: (((((((("Recurrence"[Mesh]) OR "Patient Readmission"[Mesh])) OR 

((((readmission) OR readmissions) OR recurrence) OR recurrences))) AND 

(((((((((((((((((((((((((((((((((((((("exercise therapy") OR "physical therapies") OR "physical 

therapy") OR "non-professional home care") OR "nonprofessional home care") OR "home 

nursing") OR "hospital-based home cares") OR "hospital-based home care") OR "hospital home 

care services") OR "hospital based home cares") OR "mobile health") OR eHealth) OR 

telehealth) OR telemedicine) OR "clinical pathways") OR "clinical pathway") OR "clinical 

paths") OR "clinical path") OR "critical paths") OR "critical path") OR "critical pathway") OR 

"critical pathways") OR continuity) OR referral) OR discharge) OR sub-acute care) OR subacute 

care) OR posthospital*) OR post-hospital*) OR postacute care) OR post-acute care) OR 

coordinate) OR coordination) OR post-discharge) OR postdischarge) OR transition*)) OR 

((((((((((("Case Management"[Mesh]) OR "Rehabilitation"[Mesh]) OR "Continuity of Patient 

Care"[Mesh]) OR "Patient Discharge"[Mesh]) OR "Patient Transfer"[Mesh]) OR 

"Telemedicine"[Mesh]) OR "Critical Pathways"[Mesh]) OR "Home Care Services, HospitalBased"[Mesh]) OR "Home Nursing"[Mesh]) OR "Physical Therapy Modalities"[Mesh]) OR 

"Exercise Therapy"[Mesh]))))) AND (((systematic review[ti] OR meta-analysis[pt] OR metaanalysis[ti] OR systematic literature review[ti] OR (systematic review[tiab] AND review[pt]) OR 

consensus development conference[pt] OR practice guideline[pt] OR cochrane database syst 

rev[ta] OR acp journal club[ta] OR health technol assess[ta] OR evid rep technol assess 

summ[ta] OR drug class reviews[ti]) OR (clinical guideline[tw] AND management[tw]) OR 

((evidence based[ti] OR evidence-based medicine[mh] OR best practice*[ti] OR evidence 

synthesis[tiab]) AND (review[pt] OR diseases category[mh] OR behavior and behavior 

mechanisms[mh] OR therapeutics[mh] OR evaluation studies[pt] OR validation studies[pt] OR 

guideline[pt] OR pmcbook)) OR ((systematic[tw] OR systematically[tw] OR critical[tiab] OR 

(study selection[tw]) OR (predetermined[tw] OR inclusion[tw] AND criteri*[tw]) OR exclusion 

criteri*[tw] OR main outcome measures[tw] OR standard of care[tw] OR standards of care[tw]) 

AND (survey[tiab] OR surveys[tiab] OR overview*[tw] OR review[tiab] OR reviews[tiab] OR 

search*[tw] OR handsearch[tw] OR analysis[ti] OR critique[tiab] OR appraisal[tw] OR 

(reduction[tw] AND (risk[mh] OR risk[tw]) AND (death OR recurrence))) AND (literature[tiab] 

OR articles[tiab] OR publications[tiab] OR publication[tiab] OR bibliography[tiab] OR 

bibliographies[tiab] OR published[tiab] OR unpublished[tw] OR citation[tw] OR citations[tw] 

OR database[tiab] OR internet[tiab] OR textbooks[tiab] OR references[tw] OR scales[tw] OR 

papers[tw] OR datasets[tw] OR trials[tiab] OR meta-analy*[tw] OR (clinical[tiab] AND 

studies[tiab]) OR treatment outcome[mh] OR treatment outcome[tw] OR pmcbook)) NOT 

(letter[pt] OR newspaper article[pt] OR comment[pt]))) AND (Humans[Mesh] AND 

English[lang] AND adult[MeSH]) 

ADDITIONAL SEARCH FOR PATIENT CENTERED MEDICAL HOME

Database: PubMed

Date of search: 8/27/2014

User query: ((((medical home[Title]) OR medical homes[Title]) OR pcmh[Title])) AND 

"Patient-Centered Care"[MeSH] AND (systematic[sb])

47
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

APPENDIX C. FIGURES 

FIGURE 1. LITERATURE FLOW DIAGRAM

807 citations identified from electronic database searches 

788 from PubMed on 5/02/2014

19 from PubMed on 8/27/2014

94 citations identified from reference lists of review articles 

and manual searches

901 citations compiled for review of titles and abstracts

820 titles and abstracts excluded for lack 

of relevance 

81 potentially relevant articles retrieved for further review

55 articles excluded for: 

• not meeting priority inclusion criteria

• used for background, methods, discussion

or other contextual purposes

• primary articles in VA settings:

o conducted in outpatients

o no data on key outcomes

7 systematic reviews of different 

patient populations

10 systematic reviews of different 

intervention types

17 systematic reviews of 

care transition interventions

9 primary studies in VA settings

48
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

FIGURE 2. TRANSITIONAL CARE MAP 

Setting Primary care Hospitalization Home Outpatient follow up Admission Hospital Stay Discharge Core Processes

Advanced care 

planning

Anticipatory discharge planning and care coordination

- Post-DC services (ie, DME, SNF, home health, transportation) arranged

- Patient has a clear point of contact across settings

Reassessment of 

signs/ symptoms

- Follow up call 

- Home Visit for 

high risk patients

Ongoing telephone 

follow-up (eg, 

structured telephone 

support) for select 

patients

Timely ambulatory follow 

up

Readmission risk assessment

Proactive communication

- PACT team alerted on admission

- Means of communication between primary 

care team and hospital team 

Continued communication with hospital and 

ambulatory providers at key junctures (ie, end of 

life decisions, opioid pain management, other key 

medical decisions)

DC summary 

completed and 

transmitted

Outstanding test follow 

through

Patient-level 

transition record

(PHR, AVS)

Psychosocial Needs 

assessment

Patient/ Caregiver engagement and education with focus on:

- Self-management including red flags/ warning signs

- Medication changes

- Follow up

Admission med rec DC med rec PCP med list updated

Key team members

Patient/ caregivers

PCP Hospital MD PCP

Hospital RNs, social workers, PT/OT, inpatient pharmacists home health, PT/OT Outpatient 

pharmacists

Ambulatory RNs

Transitions coaches, peers

Figure 2. This transitional care map can guide transitional care improvements, and represents the core components of an ideal transition. We suggest that many of these elements 

be incorporated into best practice for all care transitions. For example, practices of proactive communication, anticipatory discharge planning, patient/ caregiver communication, 

and timely completion of a discharge summary ought to be standard work for all patients and in any system. However, other elements, such as use of a formal readmission risk 

tool, detailed pharmacist-guided medication reconciliation, or reassessment of signs and symptoms after discharge via a home visit may be more important in some settings and 

populations. The arrows at the points of transition indicate that, in some cases, the primary care team may be able to “reach-in” to the hospital as a means of care coordination. 

Advanced care planning around goals of care at the end of life can be an important part of transitional care from primary care to the hospital, and in particular among patients 

with terminal illness or geriatric patients, can be initiated in the primary care setting and help guide inpatient care decisions, or potentially avoid unwanted admission altogether. 

Similarly, if a change in functional status is anticipated after a planned hospitalization – for example, after planned hip replacement – decisions around choice of skilled nursing 

facilities and other post-discharge needs might be best coordinated prior to hospitalization. 

49
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Proactive Communication in which the hospital team alerts primary care that a patient is hospitalized, and in which, key history from the primary care setting is communicated 

forward to the hospital team. A well-integrated and complete medical record may be sufficient in most circumstances. However, where systems are less integrated or where more 

complex medical or social factors are at play, a warm handoff from primary care to hospital providers can be beneficial. 

Anticipatory discharge planning is a key element of all hospital-to-home transitions. We suggest that all team members – including physicians, inpatient nurses, social workers, 

physical and occupational therapists, as well as family and caregivers – are supported to anticipate and prepare for post-discharge needs such as durable medical equipment, home 

health, and transportation. Multidisciplinary meetings conducted during inpatient rounds may be an efficient way to accomplish much of this discussion. 

Readmission risk assessment for the purposes of identifying patients for transitional care interventions can be performed at admission, discharge, or even in the post-discharge 

period depending on the nature of the intervention. For example, some interventions incorporate length of stay as a variable, and thus would be performed on discharge and are 

best used to guide post-discharge interventions. Other interventions are intended to begin during hospitalization, and thus are best performed early on hospitalization. See Policy 

Implications section for more discussion of risk assessment. 

Psychosocial needs assessment should assess factors such as access to outpatient care, ability to afford needed medications, health literacy and numeracy, housing, 

transportation, and social/caregiver support. These factors inform a more accurate understanding of a patient’s ability to self-manage care after hospitalization, whether caregivers 

should be involved in self-management education, and should guide decisions around role for home health or skilled nursing placement, complexity of medication regimens, and 

any additional transitional care needs that patient’s might need to be successful after hospitalization. 

Communication with hospital and ambulatory providers during hospitalization may be important at key junctures, for example, around end of life decision-making or around 

prescribing opioids in high-risk situations, where the success of the plan hinges on the patient’s outpatient providers and care environment. 

Patient/ Caregiver engagement and education should occur throughout hospitalization and utilize teach-back to assess patient understanding. Education can be tailored to 

focus on transitional care pillars which include: patient understanding of self-management including red flags and warning signs that should prompt further medical attention, 

medication changes, and a clear follow-up plan. These activities are an opportunity to improve patients’ self-efficacy and confidence in self-management, as well as empowering 

them to serve as their own advocates while transitioning across care settings. 

DC summaries should be completed within a reasonable time frame of discharge (some suggest within 24 hours of discharge), should be complete, and transmitted effectively to 

appropriate outpatient providers. Some key elements of discharge summaries include hospital course and discharge diagnoses, an accurate medication list with rationale for new 

or discontinued medications, results of key procedures, pending studies and any suggested next steps in evaluation, follow up appointments, discharge location (ie, home, name of 

SNF), suggested next steps in evaluation, and a physical examination that includes cognitive and functional status.

Patient-level transition record might vary depending on the system and patient. All patients should receive basic written instructions that include an accurate medication list and 

clear instructions to stop or start any medications and self-care instructions that avoid overly complex language. Some patients may benefit from additional written materials such 

as a pictorial medication calendar or a more detailed personal health record. For some high-risk populations (eg, CHF patients), there may be some utility in creating (or vetting 

existing) educational tools/instructions, many elements of which may be applicable to most patients, and which can have sections that are individually adaptable as well. 

Medication reconciliation, while not supported by literature to reduce readmission rates, is an expected part of any hospital admission and discharge. Depending on patient risks 

and medication complexity and existing resources this may best be performed by a pharmacist versus an inpatient provider. 

Reassessment of signs and symptoms: optimal approaches to reassessing signs and symptoms after discharge may depend on system and patient characteristics. For example, 

there is some evidence that a home visit after discharge can improve care and reduce readmissions among high-risk patients, however it is neither feasible nor cost effective for 

all patients to receive a home visit after discharge. Similarly, systems best consider who performs a phone call after hospitalization (perhaps primary care teams, to assure a close 

connection back to primary care, or perhaps the health plan to assure that all medications and equipment have been supplied, and to expedite approval and scheduling of any 

needed appointments). 

Ambulatory follow up: the optimal timing for post-discharge follow-up is unclear and likely differs based on patient need and medical acuity.

Outstanding test follow through: errors due to lack of follow through on tests (lab, imaging, pathology) pending at the time of discharge are common. It is important that there 

is a shared understanding of accountability for test follow-through among outpatient and inpatient care teams, and a seamless process for communicating outstanding tests and 

responsibility for follow through across care settings. 

50
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

APPENDIX D. INCLUSION/EXCLUSION CRITERIA 

Key Questions KQ1. What are the overlapping elements identified in 

existing systematic reviews that promote successful 

hospital-to-home transitions? 

We propose a review of systematic reviews to identify the 

common themes that have emerged from reviews that have 

focused on specific patient populations (eg, MI, pneumonia, 

COPD, and CHF). 

We will then identify randomized controlled trials that include 

diverse patient populations and test the effects of transitional 

care interventions on readmission rates (KQ2).

KQ2. How do intervention, population, and health care setting 

characteristics modify the effectiveness of transitional care 

interventions in lowering readmissions and/or reducing mortality?

a. What are the key intervention subcomponents that are common to

successful interventions?

b. How do implementation characteristics such as the facilitator, intensity,

and method of contact modify intervention effects?

c. Are there different characteristics of successful interventions in integrated

and non-integrated health systems?

d. How do the characteristics of successful interventions vary among

different patient populations?

Population Include: Adults discharged from the hospital

- any disease specific medical population (cardiovascular, respiratory illness, etc), or general medical population

- any surgical population (inclusion in KQ2 contingent on yield)

Exclude: pediatric; O/B

Intervention We will define interventions as those that include “a set of actions designed to ensure the coordination and continuity of health care as 

patients transfer between different locations or different levels of care” (Coleman 2004) and/or help prepare patients/caregivers to selfmanage their care after discharge from a hospital. 

Interventions can take place before or after discharge, or include components that span settings (aka bridging interventions). 

Key processes of interventions may include patient education, motivational interviewing, medication reconciliation, risk-based dosing, 

monitoring/remote data collection, personal health record, single point of contact, outpatient/provider follow-up, advanced care planning, and 

care coordination. 

Characteristics of the intervention, such as facilitator, recipient, intensity (frequency and duration), method of contact, and other aspects, may 

vary, and will be abstracted and analyzed as covariates. 

Comparator Usual care, or other included intervention (ie, head-to-head trial)

Outcomes of 

interest

Primary outcomes of interest: readmission rate, mortality

Secondary outcomes: 

• Quality of life

• Functional status

• ER utilization

• Long-term care placement

Readmission rate

Mortality

Timing Any timeframe

Included study 

designs

Systematic reviews, meta-analyses, meta-regression studies Controlled clinical trials

Excluded study 

designs

Observational studies, case series, case reports

51
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

Setting • Any setting within US; integrated and non-integrated

• We will include studies in other countries that have health systems, or parts of their health system, that resemble the VA

There are essentially three schemes for universal health care:

1. The UK National Health Service Model is publically financed through taxation and is characterized by state ownership of most

hospitals and clinics. Many physicians are employed by the state. 

2. The Bismarck Model uses highly regulated non-profit health insurance funds that are financed through joint employer/employee

contributions. Most hospitals are privately owned and most physicians are privately employed. 

3. The National Health Insurance Model is a hybrid of the first two. A publically financed, governmentally run single payer purchases

care from private providers. 

System Type European Asian

UK NHS Model UK, Spain, Italy, 

Norway, Finland, 

Sweden, 

Hong Kong, New 

Zealand,

Bismarck Model Germany, France, 

Belgium, the 

Netherlands, 

Switzerland

Japan

National Health 

Insurance Model

Canada Taiwan, South 

Korea, Australia

• Discharged from hospital to home

• Discharged from hospital to skilled nursing facilities

Exclude: studies of patients transitioning from outpatient setting or from skilled care facility

52
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

53  

APPENDIX E. REVIEWER COMMENTS AND RESPONSES

PR # Comment Response

Are the objectives, scope, and methods for this review clearly described?

1-8 All reviewers entered “Yes” Noted.

Is there any indication of bias in our synthesis of the evidence?

1-8 All reviewers entered “No” Noted.

Are there any published or unpublished studies that we may have overlooked?

1-3

5-7

No Noted.

4 Yes - I have heard that a study was published on the IPEC Readmissions tool, and so it seems 

odd its not even mentioned in your compilation of studies.

Thank you for the suggestion. The IPEC 

tool would not be eligible for our review 

because it does not meet inclusion criteria 

for intervention type. 

8 Yes - CMAJ 2004;170(3):345-9 Adverse events among medical patients after discharge from 

hospital NTOCC September 2008 Update, Transitions of Care Measures, Paper by the NTOCC 

Measures Work Group, 2008

Thank you for the suggestion. We 

examined the suggested study and 

determined that it does not meet inclusion 

criteria for intervention type. 

Additional suggestions or comments can be provided below. If applicable, please indicate the page and line numbers from the draft report.

1 Congratulations to the authors on a very ambitious undertaking. This is an impressive review of 

the literature, and a respectable attempt at deriving standardized, quantifiable and generalizable 

knowledge around best practices in transitional care improvement. 

Noted, thank you.

1 I agree with the author’s conclusions, and believe it is supported by the reviewed material and 

the tables. However the clarity and potential impact of this paper is reduced by a lack of 

definitions or consistency for many of the terms used throughout, such as ‘intervention,’ 

intervention component,’ intervention characteristic,’ ‘elements,’ and ‘population.’ I suspect that 

elements, components and characteristics often mean the same thing, and/or characteristics 

include all of the above, but there are examples where the authors seem to indicate that these 

terms mean something more specific, but then seem to not use them consistently for those 

specific meanings. ‘Characteristics’ is carefully defined as facilitator, recipient, intensity, etc in 

the inclusion/exclusion criteria, but there are instances in the paper that seem to imply that 

‘characteristics’ is used more generally as a way of describing variation in interventions, patients 

and setting generally. The title to Table 2 is one example. 

There were many instances where I was unsure whether or not the term ‘intervention’ meant 

‘intervention components,’ also called ‘key processes’ in the tables, or was referring to a named 

We agree that the terminology used is 

inconsistent and confusing. We have 

added definitions of intervention type, 

patient population, and intervention 

characteristics to the first paragraph of the 

Methods section. We have revised the rest 

of the report to be more consistent in the 

use of these terms. 
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

54  

PR # Comment Response

evidence-based intervention model, which is usually comprised of many components. ‘Specific 

populations’ sometimes seemed to mean clinical condition, sometimes demographic features, 

sometimes treatment setting and sometimes risk status. If all of those ways of slicing populations 

are what is meant by ‘specific’ it would be helpful for the authors to have said this plainly 

somewhere early in the paper. This is in my view exactly what much of the research in 

transitional care suffers from, and which is holding us back from comparative effectiveness 

studies, and is in fact mentioned many times in this paper, and that is a standard taxonomy. 

Table 2 categorizes interventions by main activities, but some are multi-component categories 

(eg Hospital at Home) and some are single components (f/u phone calls). This led me to be 

confused for the rest of the paper about what is meant by ‘intervention type.’

p 13 lns 43-45 Again interventions that are single component and some that are multicomponent

p 13 lns 22-25 Intervention types here is equated with processes of care, but again includes 

interventions that are single component or single processes, and interventions that are complex 

multi-component, leaving confusion about what you mean by ‘intervention’ and ‘intervention 

type.’

pp 13 - 15 This examines several individual components, but includes components likely 

included in other ‘intervention types.’ It is hard to draw conclusions from this. Although the 

authors do explain this, and note the difficulty deriving conclusions because of it, it leaves the 

reader not knowing what the authors in this paper consider to be an ‘intervention.’

p 18 first paragraph - what do the authors mean at this point by ‘intervention type’? Single 

conponent vs multi-component? The presence of the specific components showing promising 

results?

1 It would help me follow this complex paper better if the introduction included a description of 

the usual transitional care given in the VA, and how it is evolving - ie new activities that have 

been introduced for the purposes of improving care transitions and/or reducing readmissions; 

and the methods section began with an overview of the taxonomy problem (which is included in 

the results section, and is well done) with a summary of how the authors intend to define their 

own taxonomy for the rest of this paper. It would help ground the reader in the 

elements/components/characteristics that are the highest priority to examine closely, and the 

yardstick by which the paper intends to examine them. 

We have added some VA specific 

information to the background, and added 

some definitions to the first paragraph of 

the methods section. 
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

55  

PR # Comment Response

1 METHODS - The introduction describes the method for establishing patient populations and 

intervention categories and references Tables 1 and 2. Table 1 makes it clear that population 

categories are clinical; if this is what is meant by ‘population’ throughout the rest of the paper, it 

would be helpful to just state that - that populations refer to patients grouped according to 

condition. 

p 17 ln 17 This refers to ‘specific populations’ and seems to mean clinical condition only.

We agree – we have revised accordingly. 

1 P 11 - I found this discussion of taxonomies very helpful, and would have found it more helpful 

if it had been introduced in the Methods section with a definition of terms for this paper.

Agree – included the taxonomy in first 

paragraph of methods. 

1 P 12 line 41 - needs closing parens Done

1 P 13 ln 24 ‘several show promise’ needs refs Added

1 p 18 ln 29 Does ‘specific intervention’ here mean components or larger multi-component 

models?

Revised to refer to intervention types

1 p 18 lns25-26 ‘Variation of population’ seems awkward. Maybe ‘Variations in’ or ‘Variability 

of’?

Corrected

1 P 19 - might consider adding to this list ‘Development of a standard taxonomy is desparately 

needed’!

Done

1 P20 ln 30 I am assuming that the research team developed the map as a result of this review?

Would be good to state that plainly. Is this based on the review alone or the combination of the 

review and the experience within the VA? I like the map - could be a great way to categorize 

components in the future.

We were more explicit in describing this 

as part of the review. We left in the 

description of specific elements used to 

develop the map. 

1 p 21 ln 24-25 ‘Transitional care nurse’ refers to a named comprehensive intervention model. It 

would be more accurate to describe this as ‘a nurse dedicated to key activities to support better 

transitional care.’

We edited the “care transitions and 

PACT” section on page 18 (where the 

term is first used). We used the suggested 

wording after referencing the Care 

Transitions Intervention and we applied 

quotations to the term. 

1 p 25 ln 8 I am not familiar with “CBOC” Clarified

1 p 26 ln 41 ‘post discharge calls have become a major vehicle for transitional care aty the VA’ - it 

seems that this should have been introduced earlier, as one of the stated goals of this review is to 

determine what the VA should invest in for transitional care improvement. See my earlier 

comments.

As above, we added more VA-specific detail

to the background including mention of 

current use of these calls. 

1 p 27 ln 45+ There are many current initiatives doing exactly this. It might be more accurate to 

say ‘adapt the continuous quality imrpvement methods used by other initiatives for the VA 

setting and population.’

Thank you for the suggestion – we have 

revised accordingly

1 p15 ln13 ‘older Cochrane review’ - it would be helpful to put in the year this was published Done
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

56  

PR # Comment Response

because the divide in effectiveness at 2002 has already been referenced. 

1 p16 ln 28 In this section ‘population’ is defined a number of ways other than clinical condition -

demographic factors, risk status

See comments above – we clarified that 

population could refer to clinical 

condition or demographic characteristics 

in Methods section

1 Future research - Might add the need to better understand the changes in usual care before and 

after 2002 to help interpret effectiveness studies in the future.

Agree, added. 

1 Conclusions - I think the lack of a common taxonomy cannot be overstated, as it is on this that 

comparisons could be made and therefore comparative effectiveness studies be performed. 

We added this to the conclusion

1 Table 1 - The authors are clear that they did not set a timeline for readmissions as an inclusion 

criteria, but it would be helpful to include a column or otherwise note what the time to 

readmissions was for each set of reviews if possible.

We added timing information where 

available. 

1 Table 2 - Would help scan this table to put in bold those processes with statistically significant 

results.

Agree; done.

1 Figure 2. Transitional care map - Consider adding ‘activation’ to “Patient/Caregiver education” 

as it is much discussed in the transitional care literature.

Added this to the description of this item, 

and added the term “engagement”

3 General comments: This is a challenging literature base to synthesize; the authors appear to have 

captured recent systematic reviews focused on transitional care. I marked "no: for studies that 

were overlooked. However, I suggest that the authors make sure they are citing the most recent 

Cochrane review on structured telephone support/ telemonitoring interventions: Reference # 24 

("older Cochrane review" cited on page 15, line 15. I believe this was updated by the Cochrane 

collaboration (in 2008): 

http://www.thecochranelibrary.com/userfiles/ccoch/file/Telemedicine/CD007228.pdf 

The study at the suggested link (Inglis 

2010) was not included because it looks 

broadly at CHF populations, not recently 

discharged patients. 

3 In the background section of the main report (and ES) I could not get a sense of the scope of the 

readmission problem as it relates to the VA. For example, are overall readmission rates similar 

to rates in Medicare populations? And do the same conditions (HF, acute MI, etc...) account for 

similar % of total readmissions?

See earlier comment – we added VA 

specific readmissions information to the 

background section. 

3 Throughout the report, there is inconsistent use of abbreviations (particularly for CHF); for 

example page 14 (line 520 "congestive heart failure" is spelled out int the first sentence but no in 

the second. I noted a few of these cases below, but suggest word searching or having the editor 

check the final copy.

Page 3, line 58: Consider abbreviating congestive heart failure here or adding acronym if it has 

not been called out previously. "CHF" is used on page 4, line 55.

line 21: CHF could be used instead of spelling this out.

Done

3 Specific comments: Preface (ii): Person listed as the PI on page i (Devan Kansagara) does not Noted and corrected, thanks
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

57  

PR # Comment Response

appear to be listed as an author in the "recommended citation" on page ii. I am not sure if this is 

an oversight?

3 Executive Summary: page 1, first paragraph: -In line 11, I recommend that "admissions" be 

changed to readmission or readmission rates.

Done

3 -The first sentence of the executive summary is not clear and maybe a little redundant. I'm not 

sure we can say that there has been an "exponential" increase in the implementation of 

transitional care programs- certainly hospitals are increasingly focused on reducing readmission 

rates and improving care transitions. One suggestion: "Health care systems are increasingly 

focused on efforts to reduce hospital readmissions; a wide variety of evidence exists on 

interventions to reduce readmissions, and national and local quality improvement efforts focused 

on transitional care have also been developed."

This was referring to a citation showing 

the breadth and rapidity of program 

interest over a brief period of time. 

Nevertheless, we have reworded and 

appreciate the suggested language. 

3 page 2, line 14: Sentence starting with "Policy implications...." would be helpful to briefly note 

the variety of clinical and research experience.

The clinical and research experience of 

the investigators is detailed in the 

corresponding section of the main report –

we left the details out of the executive 

summary in an effort to keep it relatively 

brief. 

3 page 3, line 40: PCMH had no effect on admissions or should this be readmissions? Changed to readmissions

3 page 5, line 20: Consider using readmissions (instead of rehospitalizations) for consistency. Changed

3 Background: page 8, line line 25-26. Are there other financial penalties besides CMS's HRRP? If 

not, I would specifically list this program and maybe what patient populations are covered 

(...unless this is not relevant to the VA).

This is less relevant to VA, but we did 

edit this section to note several CMS 

initiatives. 

3 page 8, line 32-33. See comment from ES. I'm not sure that we know enough about 

implementation efforts around transitional care components/programs in order to justify using 

"exponential." It seems there is more of a concern about low rates of implementation, or 

implementation of some components (but not others) of the multicomponent interventions that 

are supported by the evidence.

As noted above, we changed the language 

accordingly. 

3 page 10, line 38. I suggest adding the specific populations (X on HF, X on acute MI...etc). We only selected one review for each 

patient population or intervention type 

category. 

3 page 12, line 43. Parentheses is missing here. I think the sentence "They found interventions 

"which" should be changed to "with"?

Changed. 

3 page 13, line 15/16. Without adversely impacting which outcomes? Suggest editing this to say 

"...shortened length of stay without increasing readmission rates" (or whatever the outcomes 

were).

Specified readmissions and mortality
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

58  

PR # Comment Response

3 page 13, line 16-19. Suggest not starting this sentence with the strength of evidence grade (but 

rather the conclusion of the study). As written, it is unclear.

Agree, changed. 

3 page 14, line 48. The sub-header here is "telephone based interventions"; I think this should be 

edited. The paragraph also seems to include telemonitoring interventions; maybe change to 

"technology based" or "Telephone-based and telemonitoring interventions."

Also, I'm not sure that this paragraph captures the uncertainty in benefit of structured telephone 

support vs. telemonitoring for HF in reducing early readmissions. One review cited appear to 

have lumped these together. Others (like ours) split them apart and found no benefit for 

telemonitoring (for reducing early readmissions or mortality). I believe the Cochrane review 

focused on outcome timings > 6 months after an index admission; if so, this should be noted. 

Some would say that "re"admissions > than 6 months after an index hospitalization don't have 

much to do with the quality of care transitions. Is there a reason why the more recent Cochrane 

review is not cited here? See comment above.

Agree. We have substantially revised this 

section and changed the subheading 

according. We distinguished the two 

interventions and noted the uncertainties 

in the evidence. We looked at the 2008 

Cochrane review, but it did not focus on 

TM interventions after discharge and 

therefore seemed less directly applicable 

to our review than the reviews chosen. 

3 page 14. line 23-26: I think it may be misleading to call out this one head to head trial of 

telemonitoring vs. a home visit. I don't have the full review in front of me, but I think this trial 

may have been rated high risk of bias (and the results here are not consistent with other 

telemonitoring trials...). Consider editing to state that there was insufficient evidence to make a 

conclusion on the comparative efficacy of intervention types (or something along these lines).

Agree, changed accordingly. 

3 page 14, line 30: I was surprised to suddenly see "hospital at home" interventions. The 

background/methods did not make it clear that these types of interventions would be included 

(although I could have missed this). I think this is a different strategy than transitional care 

interventions; both aim to reduce utilization rates, but I think some would say that the 

applicability (and perhaps patient populations) are quite different and that these intervention 

types should not be lumped together. One focuses on an alternative to acute care, while 

transitional care interventions focus on a different set of processes.

We note that the purpose of these 

interventions was often to substitute home 

care for part of a hospitalization, but also 

note that results did not vary according to 

the degree of “admission substitution”. 

While we agree hospital-at-home 

interventions are probably different from 

other types of transitions interventions, 

there is substantial overlap (post-d/c home 

visits, pt education, bridging element) and 

we would argue the patient populations 

targeted (older patients with chronic 

illness) are often the same populations 

targeted in other TC interventions. 

Furthermore, these interventions are often, 

at least in VA, brought up in the TC 

discussions and are relevant to TC related 

policy discussions. 
Transitions of Care from Hospital to Home Evidence-based Synthesis Program

59  

PR # Comment Response

3 Page 15, line 60. I'm not sure the authors of this review need to add a disclaimer about the VA 

trials finding an increased risk of readmissions (the sentence starting with "However...."). We 

don't know if these system-wide changes would have necessarily affected the results of those 

trials. If I remember correctly, the intervention in the trial by Oddone et. al. had some of the 

features of a medical home. I would just leave the sentence out, or instead add some of the 

reasons the authors of those trials cite as explanations for the increased rate of readmissions.

Agreed, we don’t know how this would 

impact readmissions and there have been 

a number of system wide changes to all 

the systems studied. 

3 Page 16, line 55. Selection of higher risk populations would only increase statistical power in 

trials if we could correctly identify patients at higher risk. This sentence seems out of place. My 

sense is that trials have focused on specific populations (such as HF) because this condition 

itself is associated with a high proportion of Medicare hospitalizations and 30-day readmissions. 

And because there is some data to indicate that these readmissions are potentially preventable. 

The use of risk-prediction tools seems like a separate issue.

We deleted the sentence about statistical 

power. We clarified some of the other 

language in order to better distinguish the use 

of simple inclusion criteria from risk 

prediction in identifying the study population. 

We believe the issue is relevant to TC 

discussions as one of the main purported uses 

of risk prediction tools has been to identify 

patients for intervention. There has been at 

least one quasi-experimental study in CHF 

patients using a risk prediction tool to identify 

intervention patients. The issue comes up 

frequently and we believe the relative lack of 

empiric data examining this approach in an 

intervention context is worth noting. 

3 Page 19, line 55. The term "sabotage" sounds very colloquial within this report. Consider 

revising and focusing on quality of patient hand-off from hospital to home, or ensuring close 

follow-up. The terms "sabotage" and "missed" sound like there is some well defined formula 

that needs to be followed. 

Agree, changed. 

3 Policy Implications: How would a VA hospital know that they needed to address transitional 

care? Is this map intended as a checklist for all hospitals to sort of inventory overall quality in 

transition processes. Or is intended for hospitals that have a higher than expected readmission 

rate for certain conditions (e.g., HRRP covered conditions)?

We anticipated it being used by all 

institutions regardless of current 

performance. We have added clarification 

and an explanation here. 

3 Page 21, line 45.I would be careful about using "high-risk" here. Seems like the previous section 

concluded that there was no evidence to support a risk-based approach to targeting patients who 

receive transitional care interventions. HBPC programs would certainly be able to provide inperson care following an admission for patients already enrolled. I wonder if one of the VA 

home-based care trials have reported data on readmission rates? If so, I would mention that here. 

Many VAs (or larger VAs) also have a heart failure specialty clinic that can identify patients 

during an inpatient admission and arrange close follow-up.

Agree – we have taken out that term and 

we’ve added a recent reference to the 

impact of HBPC on hospitalization rates. 

We appreciate the suggestion re: CHF 

clinics and have added this. 
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PR # Comment Response

3 Page 22-23; The section on risk-prediction is long (compared to other sections) given that the 

authors note the incremental benefits are unclear and the problems noted with implementation. 

Seems like this is more of a "research gap"- testing the external validity/ feasibility and 

effectiveness of various tools in VA settings.

While the point is well taken, we have 

decided to keep the section in as the 

question of risk assessment comes up very 

frequently in policy discussions and we 

felt it important to clarify the different 

approaches to risk assessment, 

acknowledging the gaps in evidence. 

3 Page 25, starting at page 46. I may be biased or missing some other review that found benefit, 

but I would disagree that using telemonitoring/transfer of physiologic data is a useful adjunct to 

preventing early readmissions for people with HF (without other intervention components). This 

paragraph seems to paint these interventions in too positive a light.

This was meant to refer to the STS 

interventions which were associated with 

long-term readmissions risk reduction. We 

changed the wording to emphasize the 

periodic contact by trained nurses (rather 

than the physiologic data) and we have 

clarified that the impact was on long-term 

readmissions. We have tried to be 

circumspect in the language, but there is 

at least some promising data in support of 

the STS interventions in CHF patients and 

the VA especially has reasons to value 

telephone-based interventions. 

3 Page 27, line 19-20. I don't think PCORI was spelled out previously in this report. Thanks - changed

3 Page 27, line 41-42. I'm not sure what "transition into the hospital" means. Is this about 

understanding the reasons for admissions? This is more challenging in some ways then looking 

at readmissions, and likely varies more by condition (compared with transition to home). 

We edited to clarify that this is about 

communication between outpatient and 

inpatient teams at the proximal end of 

hospital stay – clarified that this is simply 

a poorly understood, but potentially 

important, area for further investigation. 

Agree it may be a challenging area to 

investigate, but in our opinion was still 

important to acknowledge. 

3 Limitations section: I would note that reviews focused on different outcome timings (and trials 

mentioned had different readmission outcome timings). Interventions showing efficacy at 6 

months may not prevent early readmissions.

Agree, changed accordingly

4 In general, I love your writing. I was however waiting for the big bang of what I would walk 

away with... everything seemed to not demonstrate a whole lot, weak evidence, so whats a 

We acknowledge the need to provide 

some practical recommendations. We 
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PR # Comment Response

reader to do? You make recommendations about a model that touches many points of care "peri 

discharge", but what models do that? I know RED does, but will all your readers know that? 

Overall, impressive! Just know that your readers are likely well informed on transitions and will 

be looking for the magic pill, we don't have that, but we could offer some guidance or just make 

it more clear. Very proud of your work! 

have strived to do this within the 

constraints of the available evidence. We 

have edited the discussion to provide 

some more guidance on use of the map 

and we have included references to 

documents such as the NTOCC report that 

detail QI strategies institutions might use. 

While we would have loved to be able to 

identify an easy answer to fixing 

transitional care, we simply could not find 

one. But we would argue a shared 

understanding of the current evidence 

base is useful in guiding future 

discussions, even if there are many 

evidence gaps. 

5 I agree that the current post-discharge calls should be critically evaluated but their purpose is not 

necessarily to reduce utilization or improve outcomes. This is partially addressed on p. 26, lines 

28-37, but in a speculative way. Perhaps it could be clearer that this review was confined to 

reviews using readmissions as outcomes (in the title?) and that the conclusions reflect that focus.

We have specified our inclusion criteria in 

the methods. We added that our review 

focuses on readmissions and mortality 

outcomes in the objectives paragraph in 

both ES and main report. We also 

acknowledge this issue in the Limitations 

section. 

6 I didn't understand the attachment describing the Map you developed that facilities could use for 

doing a gap analysis. A little more instruction on the form would be helpful

We’ve added some more explanation to 

the corresponding section of the 

discussion, as well as a reference to the 

NTOCC report which provides greater 

detail about specific QI methodology. 

7 This ESP review speaks to the complexity of evaluating much of the transition literature. The 

lack of effectiveness of most of the interventions evaluated speaks to this complexity. This 

review clearly speaks to this issue.

Noted

8 There is a noticeable paucity of discussion of metrics for transitional care. While the report calls 

into question the use of readmissions alone as a metric (appropriately so) it alludes to other 

utilization measures but not enough attention is paid to other outcome and process measures 

(page 23-24). 

Most dramatically absent is the need to assess adverse events associated with inadequate 

transitions. Falls with injuries, delayed or missed diagnosis due to diagnostic study results not 

We agree and appreciate these 

suggestions. We have added a discussion 

of patient safety to the outcomes section 

and added a reference to the global trigger 

tool. 
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PR # Comment Response

being followed up or recommended testing not being completed, nosocomial infections, 

morbidity from inadequate home health arrangements, etc. do not register on the 30d 

readmission metric but are poor outcomes with high impact to patients and resources. 

There are published process measures and outcome measures in addition to utilization measures. 

The NTOCC (National Transitions of Care Coalition) defines various measures categories 

(structure, process, outcomes). This is a start but probably not the best paradigm for measuring 

transitional care. 

Additionally, the global trigger tool as a mechanism for capturing adverse events was not 

examined. Utilization measures (readmissions, ED visits, etc.) are based on financial outcomes 

for CMS first, and patient outcomes second. They are not adequate for addressing the enormity 

of health outcomes that suffer from inadequate transitions. Mortality is a balancing measure for 

readmissions. In the case of heart failure, if an institution has a high readmission rate but a lower 

than average mortality rate, the case can be made for enhanced access as a contributing factor. 

8 Was the SHM BOOST data included in the studies that were reviewed? BOOST data was 

published in 2013 and I wasn't sure if it was included in the analysis. Their emphasis on QI 

methodology as a way to improve transitional care is an important consideration.

We are aware of this observational study, 

but since this was a review of reviews we 

did not formally include individual studies 

that were not included in reviews (and this 

study would not have been included in 

recent systematic reviews most of which 

examined only trials). We agree that a 

complete discussion of TC improvement 

needs to acknowledge QI methods that 

can be used to affect change. Such a 

discussion is beyond the scope of this 

review, but we have added a sentence to 

the discussion about the TC map that 

acknowledges this gap and references the 

NTOCC report.