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J Nurs Care Qual. 2018 Jul/Sep;33(3):221-228. doi: 10.1097/NCQ.0000000000000294.

Hospital-Community Partnerships to Aid Transitions for Older Adults: Applying the Care Transitions Framework.

Author information

Palo Alto Medical Foundation Research Institute, Mountain View, California (Dr Hung and Mss Truong and Yakir); and Division of Geriatrics, University of California San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, California (Dr Nicosia).


This study examined the implementation and hospitalwide scaling of a community-based transitional care program to reduce readmissions among adults 65 years or older. Our analysis was guided by the Care Transitions Framework and was based on semistructured interviews with program implementers to identify intervention successes, barriers, and outcomes beyond reducing readmissions. Such outcomes included the program's critical role in providing a safety net and transition to more advanced care, and redefining intervention success from more patient-centered perspectives.

[Indexed for MEDLINE]

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