TY - JOUR
T1 - Components of Comprehensive and Effective Transitional Care
AU - Naylor, Mary D.
AU - Shaid, Elizabeth C.
AU - Carpenter, Deborah
AU - Gass, Brianna
AU - Levine, Carol
AU - Li, Jing
AU - Malley, Ann
AU - McCauley, Kathleen
AU - Nguyen, Huong Q.
AU - Watson, Heather
AU - Brock, Jane
AU - Mittman, Brian
AU - Jack, Brian
AU - Mitchell, Suzanne
AU - Callicoatte, Becky
AU - Schall, John
AU - Williams, Mark V.
N1 - Publisher Copyright:
© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society
PY - 2017/6
Y1 - 2017/6
N2 - 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.
AB - 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.
KW - accountability
KW - complexity management
KW - continuity
KW - education
KW - engagement
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U2 - 10.1111/jgs.14782
DO - 10.1111/jgs.14782
M3 - Article
C2 - 28369722
AN - SCOPUS:85017136361
SN - 0002-8614
VL - 65
SP - 1119
EP - 1125
JO - Journal of the American Geriatrics Society
JF - Journal of the American Geriatrics Society
IS - 6
ER -