Components of Comprehensive and Effective Transitional Care

Mary D. Naylor, Elizabeth C. Shaid, Deborah Carpenter, Brianna Gass, Carol Levine, Jing Li, Ann Malley, Kathleen McCauley, Huong Q. Nguyen, Heather Watson, Jane Brock, Brian Mittman, Brian Jack, Suzanne Mitchell, Becky Callicoatte, John Schall, Mark V. Williams

Research output: Contribution to journalArticlepeer-review

128 Scopus citations


Transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve health outcomes and reduce preventable hospital readmissions, yet little is known about the critical elements of effective TC and how they relate to patients’ and caregivers’ needs and experiences. To address this gap, the Patient-Centered Outcomes Research Institute (PCORI) funded a national study, Achieving patient-centered Care and optimized Health In care transitions by Evaluating the Value of Evidence (Project ACHIEVE). A primary aim of the study is the identification of TC components that yield desired patient and caregiver outcomes. Project ACHIEVE established a multistakeholder workgroup to recommend essential TC components for vulnerable Medicare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components and then analyzed how well the set aligned with real-world patients' and caregivers' experiences. Through this process, the workgroup identified eight TC components: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients' and caregivers' well-being, care continuity, and accountability. Although the degree of attention given to each component will vary based on the specific needs of patients and caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all Medicare beneficiaries.

Original languageEnglish
Pages (from-to)1119-1125
Number of pages7
JournalJournal of the American Geriatrics Society
Issue number6
StatePublished - Jun 2017

Bibliographical note

Funding Information:
The authors would like to acknowledge the contributions made by the TCCMW that resulted in the findings reported in this manuscript. See Appendix S1 for the complete list of TCCMW members. We gratefully acknowledge Karen B. Hirschman, PhD, MSW (University of Pennsylvania School of Nursing; Project ACHIEVE Co-Investigator) for her review and editorial support of this manuscript. Funding Sources: This work was supported through PCORI Contract TC-1403–14049. All statements in this publication, including its findings and conclusions, are solely those of the authors and do not necessarily represent the views of PCORI, its Board of Governors, or its Methodology Committee. Dr. Ann Malley was supported by National Institutes of Health, Ruth L. Kirschstein National Research Service Award T32NR009356. Conflict of Interest: The authors have no conflicts of interest to declare. Author Contributions: All authors were involved in the deliberations regarding key concepts and design, analysis, and interpretation of evidence, as well as in the preparation of this manuscript. Sponsor's Role: Other than providing project funding, PCORI did not have a role in the deliberations outlined under authors’ contributions.

Publisher Copyright:
© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society


  • accountability
  • complexity management
  • continuity
  • education
  • engagement

ASJC Scopus subject areas

  • Geriatrics and Gerontology


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