The DOI matches its Crossref record; 5 of the 6 references it cites were found in a registry or an index.
Improving patient outcomes with better care transitions: The role for home health
Open accessAbstract
Patients, particularly the old and frail, are especially vulnerable at the time of hospital discharge. Fragmentation of care, characterized by miscommunications and lack of follow-up, can lead to oversights in diagnosis and management. The frequent result is avoidable rehospitalization. Amedisys, a home health and hospice organization, created and tested a care transitions initiative for its impact on patients' quality of life and avoidable rehospitalizations. The initiative was carried out in three academic institutions with 12 months of observation. The results suggested reduced hospital readmissions and a critical role for the home health industry in improving patient outcomes and reducing costs.
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“Post-discharge follow-up was linked to carers understanding of condition management, and confidence to support the patient’s needs [28, 44, 53–55, 58–60, 62–65].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [55]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“Some systems aimed to improve patient safety during transitions by assigning HCPs to facilitate care coordination. This included acting as a single point of contact in the initial post-discharge period, to improve communication, reduce confusion and subsequently prevent avoidable rehospitalisation, however evidence of their effectiveness was limited (CMOC23) [53, 55, 60].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [55]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“In this review, assigning a single care coordinator was suggested as a potential solution, but rarely implemented [53, 55, 60, 99].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [55]
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Citations
Cites
Naylor, M. D., Brooten, D., Campbell, R., Jacobsen, B. S., Mezey, M. D., Pauly, M. V., & Schwartz, J. S. (1999) · JAMA · doi:10.1001/jama.281.7.613 · Cited by 1,831
Proportion of hospital readmissions deemed avoidable: a systematic review
van Walraven, C., Bennett, C. L., Jennings, A., Austin, P. C., & Forster, A. J. (2011) · Canadian Medical Association Journal · doi:10.1503/cmaj.101860 · Cited by 732
Coleman, E. A., Smith, J. D., Frank, J. C., Min, S., Parry, C., & Kramer, A. M. (2004) · Journal of the American Geriatrics Society · doi:10.1111/j.1532-5415.2004.52504.x · Cited by 645
Posthospital Care Transitions: Patterns, Complications, and Risk Identification
Coleman, E. A., Min, S., Chomiak, A., & Kramer, A. M. (2004) · Health Services Research · doi:10.1111/j.1475-6773.2004.00298.x · Cited by 423
Patients' and Caregivers' Transition from Hospital to Home: Needs and Recommendations
Weaver, F. M., Perloff, L., & Waters, T. M. (1999) · Home Health Care Services Quarterly · doi:10.1300/j027v17n03_03 · Cited by 72
Research works printed but not linked: 1
- Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006; 166:1822-1828.
Cited by
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Palmer, K., Marengoni, A., Forjaz, M. J., Jurevičienė, E., Laatikainen, T. K., Mammarella, F., Muth, C., Navickas, R., Prados‐Torres, A., Rijken, M., et al. (2017) · Health Policy · doi:10.1016/j.healthpol.2017.09.006 · Cited by 317
Hopman, P., de Bruin, S. R., Forjaz, M. J., Rodríguez‐Blázquez, C., Tonnara, G., Lemmens, L. C., Onder, G., Baan, C. A., & Rijken, M. (2016) · Health Policy · doi:10.1016/j.healthpol.2016.04.002 · Cited by 195
Care transition strategies in Latin American countries: an integrative review
Lima, M. A. D. D. S., de Magalhães, A. M. M., Oelke, N. D., Marques, G. Q., Lorenzini, E., Weber, L. A. F., & Fan, I. (2018) · Revista gaúcha de enfermagem · doi:10.1590/1983-1447.2018.20180119 · Cited by 103
The continuity of hospital nursing care for Primary Health Care in Spain
da Costa, M. F. B. N. A., de Andrade, S. R., Soares, C. F., Pérez, E. I. B., Tomás, S. C., & Bernardino, E. (2019) · Revista da Escola de Enfermagem da USP · doi:10.1590/s1980-220x2018017803477 · Cited by 76
Brazilian version of the Care Transitions Measure: translation and validation
Acosta, A. M., Lima, M. A. D. D. S., Marques, G. Q., Levandovski, P. F., & Weber, L. A. F. (2016) · International Nursing Review · doi:10.1111/inr.12326 · Cited by 63
Metadata
- Authors
- Fleming, M. O., & Haney, T. T.
- Venue
- Cleveland Clinic Journal of Medicine
- Publisher
- Cleveland Clinic Journal of Medicine
- Published
- 2013-01
- Volume
- 80
- Issue
- 1 e-suppl 1
- Pages
- e-S2-e-S6
- ISSN
- 0891-1150 (ISSN-L)
- 1939-2869
- OpenAlex
- W2326434799
- Cited by
- 22
- References
- 6
- Citations by year
- 2025: 1 · 2023: 2 · 2022: 1 · 2021: 1 · 2020: 2 · 2019: 1 · 2018: 2 · 2017: 3 · 2016: 5 · 2015: 1 · 2014: 2 · 2013: 1
- FWCI
- 2.96
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Cleveland Clinic Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Nursing › Leadership and Management › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Geriatrics and Gerontology › Geriatric Care and Nursing Homes
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Keywords
- care transitions, hospital discharge, home health care, care fragmentation, patient follow-up, quality of life, patient outcomes, health care costs
- MeSH terms
- Aged, Aged, 80 and over, Continuity of Patient Care, Dementia, Emergency Service, Hospital, Female, Medicare, Heart Failure, Home Care Services, Humans, Interprofessional Relations, Life Expectancy, Patient Discharge, Patient Education as Topic, Patient Readmission, Population Dynamics, United States, Frail Elderly, Patient-Centered Care
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