Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website

Management Brief No. 92

» Back to list of all Management Briefs

Management eBriefs
Issue 92March 2015

A Review: Transitions of Care from Hospital to Home

The hospital-to-home transition marks an abrupt shift from intensive, provider-driven care to self-managed care, and, often, from one set of inpatient providers to an entirely different set of outpatient providers. Uncertain how to manage their health care after hospital discharge, patients in both VA and non-VA settings are at increased risk for adverse events, and for hospital readmissions, which are common and costly. Some 15-20% of Veterans hospitalized with higher-risk conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease, or myocardial infarction are readmitted within 30 days, while nearly one-quarter of those with chronic mental illness experience a 30-day readmission. In 2011, the total cost of 30-day readmissions to the Veterans Health Administration (VHA) was $1.2 billion.

There were several early studies showing that interventions designed to improve the transition of care from hospital to home can reduce readmission rates. However, a number of subsequent studies have not consistently found benefit. Transitional care interventions are often complex and involve multiple components, can focus on different aspects of the care transition, and have been tested in varying patient populations and healthcare settings.

To better understand how the transitional care literature could be used to inform efforts by VHA to improve hospital to home care transitions, the Evidence-based Synthesis Program (ESP) Coordinating Center at the VA Portland Health Care System produced a report broadly summarizing evidence on the effects of transitional care interventions. The authors conducted a review of systematic reviews and identified key themes that have emerged across the transitional care intervention literature that clarify which types of intervention are associated with reduced readmissions and/or mortality, whether intervention effects differ depending on the setting in which they are implemented, and whether effects differ across patient populations. The report also outlines potential policy implications based on the themes emerging from the evidence as well as the report authors' own clinical, research, and policy experience with transitional care within VHA.

Results: No One-Size-Fits-All Approach

The report, which summarized 17 systematic reviews, emphasized the lack of strong evidence to guide broad-based adoption of any specific transitional care intervention. In general, the report found that successful interventions are more comprehensive, touch on more aspects of the care transition, extend beyond the hospital stay, and are flexible enough to respond to individual patient needs. The authors interpret these findings to mean there are many potential pathways to readmission, and that a focus on specific aspects of the care transition in isolation is unlikely to yield big changes for a population of patients.

The report recommends that each institution use a standardized approach to diagnose transitional care gaps, and report authors have created a transitional care "map" that could be used for such assessments (see Figure 2 below). While the report does not suggest that each step is necessary for every patient, VHA could harness existing infrastructures such as PACT and home-based primary care to accomplish pieces of the care transition that had previously been accomplished in the intervention literature by additional transitional care nurses. Because some transitional care intervention activities can be resource-intensive, the report outlines the potential merits and pitfalls of risk assessment to identify high-risk patients for intervention. The report also urges caution in the exclusive focus on hospital readmissions, both because of uncertainties about its validity as a measure of quality and because other patient safety and care outcomes may be important. Finally, report authors suggest that VHA critically examine the current broad-based implementation of post-discharge telephone calls.

Limitations and Research Gaps

Report authors found an overarching need for better evidence to guide selection and implementation of complex, multicomponent transitional care interventions in different settings. The report notes that one of the major weaknesses of the transitional care literature is the marked variation in intervention definitions, timing of outcome follow-up, and descriptions of interventions and usual care. As VHA conducts more research in this field, use of taxonomies to guide study design and description may help standardize reporting. In addition to this work, there are a number of more specific areas of investigation listed in the main report including an urgent need for more work in populations important to VHA, including those undergoing surgery, those with serious mental illness, and marginally housed patients. There is also a need for more comparative effectiveness research, the development of continuous quality improvement mechanisms that integrate inpatient and outpatient personnel, and evaluation of methods to incorporate patient experience and safety outcomes. Transitional care interventions have not been well studied within integrated health systems and within the medical home context. Future work should focus on how best to incorporate outpatient teams into transitional care improvement processes.

figure 2: transitional care map

Important Considerations About the Transitions Map

The report notes that the map is meant to be used as a framework for discussing systemic gaps and opportunities for improvement for different populations of patients. It has not been tested empirically and its steps are not necessarily meant to apply to all patients. It should not be used as a basis for evaluating care quality or developing quality metrics.

The report suggests that some elements represent best practice for all care transitions. For example, practices of proactive communication, anticipatory discharge planning, patient/caregiver communication, and timely completion of a discharge summary ought to be standard work for all patients and in any system. However, other elements, such as use of a formal readmission risk tool, detailed pharmacist-guided medication reconciliation, or reassessment of signs and symptoms after discharge via a home visit may be more important in some settings and populations. The authors indicate they do not know whether and when in-person post-discharge follow-up is needed for all patients, but the means to provide follow-up proactively for the subsets of patients who require it should be in place. A few of the steps, such as advanced care planning (ie, end-of-life decision-making) and proactive communication at the point of admission have not been well studied, but the authors believe they represent promising areas for future research and are appropriate to discuss in the overall context of care transitions.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers and to disseminate these reports throughout VA.

Kansagara D, Chiovaro JC, Kagen D, Jencks S, Rhyne K, O'Neil M, Kondo K, Relevo R, Motu'apuaka M, Freeman M, Englander H. Transitions of care from hospital to home: a summary of systematic evidence reviews and recommendations for transitional care in the Veterans Health Administration. VA-ESP Project #05-225; 2014.

Please feel free to forward this information to others!

Read past HSR&D Management e-Briefs on the HSR&D website.

This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.


This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

See all reports online.

Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.