Care Transitions

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Department of Health and Human Services - Transitional Care Management Services

Scientific Articles

Recent Articles (Added 1/22)

Dawson NL, Hull BP, Vijapura P, et al. Home Telemonitoring to Reduce Readmission of High-Risk Patients: a Modified Intention-to-Treat Randomized Clinical Trial. J Gen Intern Med. 2021;36(11):3395-3401. doi:10.1007/s11606-020-06589-1. Abstract.

Prior Articles:

Dowling R. (2016, June 10). How to bill and code transitional care management the right way. Article.

Jones CD, Burke RE. Annals for Hospitalists Inpatient Notes - Getting Past the “Black Box”—Opportunities for Hospitalists to Improve Postacute Care Transitions. Ann Intern Med. 2018;168:HO2–HO3. doi: 10.7326/M18-0940. Article. 

Kang Y, Mondesir FL, Young D, et al. Home Healthcare Nursing Visits for Nonhomebound Patients With Heart Failure After Hospital Discharge: A Quality-Improvement Pilot Project. Home Healthc Now. 2021;39(1):25-31. doi:10.1097/NHH.0000000000000925. Abstract.

MacDonell R, Woods O, Whelan S, et al. Interventions to standardise hospital care at presentation, admission or discharge or to reduce unnecessary admissions or readmissions for patients with acute exacerbation of chronic obstructive pulmonary disease: a scoping review. BMJ Open Respir Res. 2020;7(1):e000733. doi:10.1136/bmjresp-2020-000733. AbstractArticle.

Radhakrishnan K, Jones TL, Weems D, Knight TW, Rice WH. Seamless Transitions: Achieving Patient Safety Through Communication and Collaboration. J Patient Saf. 2018 Mar;14(1):e3-e5. Abstract.

Werner NE, Tong M, Borkenhagen A, Holden RJ. Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach. Gerontologist. 2019 Mar 14;59(2):303-314. Abstract.

Xu W, Hu H, Mao Y. Questionnaire Survey-Based Quantitative Assessment of the Impact of Transitional Care on Self-Management of Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease. Comput Math Methods Med. 2021;2021:3634548. Published 2021 Nov 13. doi:10.1155/2021/3634548. AbstractArticle.