Components of Comprehensive and Effective Transitional Care

In Journal of the American Geriatrics Society, Mary Naylor and colleagues identify components of the Transitional Care model that provide the desired patient and caregiver outcomes. For decades, the Transitional Care (TC) model has worked to prevent re-hospitalizations and their associated costs, however little is known about the specific factors that make TC effective. The authors formed a workgroup to identify a preliminary set of components. The workgroup conducted focus groups and interviews with patients and caregivers, and created an advisory group comprised of patient and caregiver representatives, in order to refine the list. A case study of TC was also utilized to understand how the identified components matched up with real-world patient and caregiver TC experiences. The authors find that eight TC components are central to effective care. These components include: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients’ and caregivers’ well-being, care continuity, and accountability. The authors recommend that although the degree of attention given to each component will vary based on specific needs, health systems must address all components to ensure optimal TC for all beneficiaries.