Elderly, chronically ill people experience frequent changes in health status that require
transitions among health care providers and settings. This issue brief describes two projects …

Older adults with multiple chronic conditions complicated by other risk factors, such as
deficits in activities of daily living or social barriers, experience multiple challenges in …

Addressing the health care needs of older adults coping with multiple conditions and their
family caregivers in a person-and family-centered, safe, effective, efficient, equitable, and …

Despite a growing body of evidence that adaptations of evidence-based interventions (EBI)
are ubiquitous, few studies have examined the nature and rationale for modifications to the …

Transitional care (TC) has received widespread attention from researchers, health system
leaders, clinicians, and policy makers as they attempt to improve health outcomes and …

In the US, older adults hospitalized with acute episodes of chronic conditions often are
rehospitalized within 30 days of discharge. Numerous studies reveal that poor management …

Under the Affordable Care Act of 2010, a variety of transitional care programs and services
have been established to improve quality and reduce costs. These programs help …

Objective To evaluate the impact of translating into a large US health plan, the Transitional
Care Model (TCM), an evidence‐based approach to address the needs of chronically ill …

Background Poorly managed hospital discharges and care transitions between health care
facilities can cause poor outcomes for both patients and their caregivers. Unfortunately, the …

Older adults are at high risk for gaps in care as they move between health care providers
and settings during the course of illness, such as following hospital discharge. These gaps …