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1,525 Results Found

  • Article
  • Open Access
4 Citations
3,192 Views
12 Pages

Rehabilitation Nurse’s Perspective on Transitional Care: An Online Focus Group

  • Rita Pedrosa,
  • Óscar Ferreira and
  • Cristina Lavareda Baixinho

5 April 2022

The increasing incidence of chronic and dependence leads to the need for hospitalization and adaptation in the process of returning home, as well as transition between care levels to ensure continuity of care. The World Health Organization has been w...

  • Article
  • Open Access
2 Citations
2,895 Views
10 Pages

Transitional Care Program in Reducing Acute Hospital Utilization in Singapore

  • Chong Yau Ong,
  • Jun Jie Angus Ng,
  • Kar Kwan Sandra Joanne Ng,
  • Pei Yoke Tay and
  • Mui Hua Jean Lee

28 October 2024

(1) Background: The evidence to support transitional care in reducing acute hospital utilization is variable. Despite changes in the healthcare landscape with a rapidly aging population, there is a lack of local and regional studies to evaluate the e...

  • Review
  • Open Access
39 Citations
12,131 Views
18 Pages

Heart failure (HF) is a life-limiting illness and presents as a gradual functional decline with intermittent episodes of acute deterioration and some recovery. In addition, HF often occurs in conjunction with other chronic diseases, resulting in comp...

  • Review
  • Open Access
6 Citations
10,700 Views
16 Pages

Transitional Care Interventions in Improving Patient and Caregiver Outcomes After Discharge: A Scoping Review

  • Giulia Marini,
  • Jessica Longhini,
  • Elisa Ambrosi,
  • Federica Canzan,
  • Hanne Konradsen and
  • Zarina Nahar Kabir

4 February 2025

Background. Caregivers play a fundamental role in the complexity of the transitional process between different healthcare settings. Current research shows that caregiver preparedness can affect the quality and efficacy of post-hospital care, therefor...

  • Systematic Review
  • Open Access
10 Citations
3,028 Views
11 Pages

Transitional Care in Pediatric Brain Tumor Patients: A Systematic Literature Review

  • Florian Ebel,
  • Ladina Greuter,
  • Raphael Guzman and
  • Jehuda Soleman

Background: Due to advances in the treatment of pediatric brain tumors (PBT), an increasing number of patients are experiencing the transition from the pediatric to the adult health care system. This requires efficient transitional models. Methods: W...

  • Review
  • Open Access
4 Citations
2,821 Views
15 Pages

15 November 2024

This study was conducted to identify the key elements of transitional care for families with pre-term infants in South Korea. We used an integrative review methodology proposed by Whittemore and Knafle. During the problem identification step, the rev...

  • Review
  • Open Access
1 Citations
473 Views
10 Pages

Transitional Care in Cardiorenal Patients: A Proposal for an Integrated Model

  • Caterina Carollo,
  • Alessandra Sorce,
  • Salvatore Evola,
  • Giacinto Fabio Caruso,
  • Emanuele Cirafici,
  • Massimo Giuseppe Tartamella and
  • Giuseppe Mulè

Heart failure (HF) and chronic kidney disease (CKD) are prevalent conditions in older adults, often coexisting and significantly increasing the risk of hospitalization, cardiovascular events, and mortality. Traditional hospital-based care, while esse...

  • Article
  • Open Access
7 Citations
3,666 Views
12 Pages

Transitional Care Management from Emergency Services to Communities: An Action Research Study

  • José Batista,
  • Carla Munhoz Pinheiro,
  • Carla Madeira,
  • Pedro Gomes,
  • Óscar Ramos Ferreira and
  • Cristina Lavareda Baixinho

In recent years, nurses have developed projects in the area of hospital to community transition. The objective of the present study was to analyze the transitional care offered to elderly people after they used emergency services and were discharged...

  • Article
  • Open Access
1,615 Views
15 Pages

Background/Objectives: To examine shifts and challenges in transitional care practices during COVID-19 and the adaptive strategies developed by Transitional Care Nurses (TCNs) in response. Methods: A qualitative descriptive study was conducted using...

  • Article
  • Open Access
13 Citations
6,772 Views
10 Pages

The Discharge Companion Program: An Interprofessional Collaboration in Transitional Care Model Delivery

  • Jennifer Bingham,
  • Patrick Campbell,
  • Kate Schussel,
  • Ann M. Taylor,
  • Kevin Boesen,
  • Amanda Harrington,
  • Sandra Leal and
  • Terri Warholak

To reduce readmission rates and avoid financial penalties from the Centers for Medicare and Medicaid Services, hospitals are seeking to implement innovative transitions of care (TOC) programs. This retrospective study evaluated the Discharge Companio...

  • Perspective
  • Open Access
2,152 Views
13 Pages

28 November 2024

Background: Spinal cord injuries (SCI) are devastating conditions which often cause multiple permanent physical impairments and psychosocial complications. Discharge from hospital is often delayed and precious health resources are consumed. In Hong K...

  • Article
  • Open Access
10 Citations
3,052 Views
11 Pages

Telerehabilitation in the Transitional Care of Patients with Sequelae Associated with COVID-19: Perception of Portuguese Nurses

  • Neuza Reis,
  • Maria José Costa Dias,
  • Luís Sousa,
  • Inês Agostinho,
  • Miguel Toscano Ricco,
  • Maria Adriana Henriques and
  • Cristina Lavareda Baixinho

The COVID-19 pandemic brought many changes and challenges to health professionals, due to a lack of knowledge when dealing with the disease, fear of contagion, and the sequelae that characterize long COVID. To deal with this situation, respiratory re...

  • Article
  • Open Access
17 Citations
5,341 Views
10 Pages

Impact of Pharmacist Involvement on Telehealth Transitional Care Management (TCM) for High Medication Risk Patients

  • Jessica Cole,
  • Nick Wilkins,
  • Maeghan Moss,
  • Danny Fu,
  • Paige Carson and
  • Linda Xiong

25 November 2019

This pilot study sought to evaluate the impact of pharmacist involvement in the preexisting telehealth transitional care management (TCM) program at Atrium Health on the quality and safety of the medication discharge process for high medication risk...

  • Article
  • Open Access
1,473 Views
12 Pages

Patient and Family Perspectives on Integrated Transitional Care for Anorexia Nervosa in Mantova, Italy

  • Debora Bussolotti,
  • Giovanni Barillà,
  • Antonia Di Genni,
  • Martina Comini,
  • Alberto Gallo,
  • Mariateresa Torre,
  • Laura Orlando,
  • Beatrice Mastrolorenzo,
  • Eva Corradini and
  • Paola Accorsi
  • + 7 authors

30 August 2025

Background/Objectives: The child and adolescent mental health service (CAMHS) hand-over to adult mental health service (AMHS) remains an ongoing shortfall in eating disorder (ED) treatment, typically in tandem with diagnostic drift, heightened suicid...

  • Article
  • Open Access
6 Citations
2,017 Views
6 Pages

Evaluation of Health Care Providers Satisfaction with the Implementation of a Transitional Pain Service

  • Manouk Admiraal,
  • Jeroen Hermanides,
  • Markus W. Hollmann and
  • Henning Hermanns

9 January 2023

Chronic postsurgical pain develops in 10% of patients undergoing surgery. Recently, multidisciplinary, patient-tailored interventions, such as a Transitional Pain Service (TPS) have been developed and implemented to improve perioperative pain managem...

  • Article
  • Open Access
879 Views
12 Pages

Continuous Wireless Vital Sign Sensors for Detecting Severe Deviations at a Transitional Care Facility—An Observational Feasibility Study

  • Jesper Mølgaard,
  • Camilla Haahr-Raunkjaer,
  • Søren Straarup Rasmussen,
  • Loraine Villacorte Andersen,
  • Christian S. Meyhoff and
  • Eske K. Aasvang

14 November 2025

After hospital admissions, patients may be discharged to a transitional care facility if they are considered physically or mentally unable to be at home. This study aimed to assess the feasibility of continuous wearable vital sign monitoring (CVSM) a...

  • Article
  • Open Access
2 Citations
2,833 Views
9 Pages

27 October 2022

Background and Objectives: The main objective of a transitional care program (TCP) is to detect patients with early deterioration following intensive care unit (ICU) discharge in order to reduce unplanned ICU readmissions. Consensus on the effectiven...

  • Article
  • Open Access
34 Citations
7,373 Views
16 Pages

Stroke is a major cause of disability and mortality worldwide; yet; prior to this study; there had been no sufficient evidence to support the effectiveness of various transitional care interventions (TCI) on the disability and mortality of stroke sur...

  • Article
  • Open Access
7 Citations
5,111 Views
11 Pages

The Lived Experience of Caregivers in the Older Stroke Survivors’ Care Pathway during the Transitional Home Program—A Qualitative Study

  • Mayra Veronese,
  • Silvio Simeone,
  • Michele Virgolesi,
  • Cristiana Rago,
  • Ercole Vellone,
  • Rosaria Alvaro and
  • Gianluca Pucciarelli

Background: stroke is a major cause of disability and death, globally. Many stroke survivors live with disabilities, requiring significant caregiving support. Caregivers often feel unprepared and burdened, experiencing isolation and health declines....

  • Article
  • Open Access
6 Citations
3,202 Views
13 Pages

Telerehabilitation Intervention in Transitional Care for People with COVID-19: Pre-Post Study with a Non-Equivalent Control Group

  • Neuza Reis,
  • Maria José Costa Dias,
  • Luís Sousa,
  • Filipa Canedo,
  • Miguel Toscano Rico,
  • Maria Adriana Henriques and
  • Cristina Lavareda Baixinho

16 September 2023

SARS-CoV-2 infection and its resulting sequelae have increased the prevalence of people with respiratory symptoms, with impacts on functional capacity, quality of life, anxiety, depression, and mental health. To mitigate this problem, one challenge h...

  • Article
  • Open Access
1,389 Views
17 Pages

Low Maternal Care and Protection and Body Image Dissatisfaction as Psychopathological Predictors of Binge Eating Disorder in Transitional-Age Youth

  • Emanuela Bianciardi,
  • Rossella Mattea Quinto,
  • Ester Longo,
  • Valentina Santelli,
  • Lorenzo Contini,
  • Alberto Siracusano,
  • Cinzia Niolu and
  • Giorgio Di Lorenzo

23 August 2025

Background: Binge eating disorder (BED) frequently arises during the transitional age (18–25 years), a critical developmental period characterized by challenges in autonomy, identity formation, and interpersonal functioning. This study investig...

  • Protocol
  • Open Access
2 Citations
3,159 Views
19 Pages

The Impact of a Video-Educational and Tele-Supporting Program on the Caregiver–Stroke Survivor Dyad During Transitional Care (D-STEPS: Dyadic Support Through Tele-Health and Educational Programs in Stroke Care): A Longitudinal Study Protocol

  • Davide Bartoli,
  • Francesco Petrosino,
  • Emanuela Nuccio,
  • Vincenzo Damico,
  • Cristiana Rago,
  • Mayra Veronese,
  • Michele Virgolesi,
  • Rosaria Alvaro,
  • Ercole Vellone and
  • Gianluca Pucciarelli
  • + 1 author

18 August 2025

Introduction: Stroke is a leading cause of long-term disability and substantially affects the quality of life (QoL) of both survivors and their caregivers. The transition from hospital to home is a vulnerable period characterized by discontinuity of...

  • Systematic Review
  • Open Access
7 Citations
5,075 Views
16 Pages

This study aimed to systematically review the effects of transitional care programs on healthcare use and quality of life in patients with chronic obstructive pulmonary disease (COPD). Several databases were searched for randomized controlled trials...

  • Article
  • Open Access
3 Citations
5,289 Views
15 Pages

Effectiveness of Transitional Care Program among High-Risk Discharged Patients: A Quasi-Experimental Study on Saving Costs, Post-Discharge Readmissions and Emergency Department Visits

  • Moonseong Heo,
  • Kevin Taaffe,
  • Ankita Ghadshi,
  • Leigh D. Teague,
  • Jeffrey Watts,
  • Snehal S. Lopes,
  • Peter Tilkemeier and
  • Alain H. Litwin

Transitional care programs (TCPs), where hospital care team members repeatedly follow up with discharged patients, aim to reduce post-discharge hospital or emergency department (ED) utilization and healthcare costs. We examined the effectiveness of T...

  • Article
  • Open Access
2 Citations
3,129 Views
24 Pages

Evaluation of a Model of Transitional Care After Preterm Birth on Parents’ Mental Health and Self-Efficacy: A Randomized Controlled Pilot Trial

  • Natascha Schuetz Haemmerli,
  • Liliane Stoffel,
  • Kai-Uwe Schmitt,
  • Tilman Humpl,
  • Mathias Nelle,
  • Odile Stalder and
  • Eva Cignacco

18 October 2024

Background/Objectives: Parents of premature infants experience depression, anxiety, post-traumatic stress disorder, and increased stress, which can negatively impact parent–infant relationships and infant development. To reduce negative consequ...

  • Article
  • Open Access
17 Citations
1,134 Views
8 Pages

The Experiences of Cancer Survivors While Transitioning from Tertiary to Primary Care

  • B.B. Franco,
  • L. Dharmakulaseelan,
  • A. McAndrew,
  • S. Bae,
  • M.C. Cheung and
  • S. Singh

1 December 2016

Purpose: In current fiscally constrained health care systems, the transition of cancer survivors to primary care from tertiary care settings is becoming more common and necessary. The purpose of our study was to explore the experiences of survivors w...

  • Article
  • Open Access
6 Citations
3,330 Views
19 Pages

On the Necessity of a Geriatric Oral Health Care Transition Model: Towards an Inclusive and Resource-Oriented Transition Process

  • Ina Nitschke,
  • Siri Nitschke,
  • Cornelius Haffner,
  • Bernhard A. J. Sobotta and
  • Julia Jockusch

People in need of care also require support within the framework of structured dental care in their different life situations. Nowadays, deteriorations in oral health tend to be noticed by chance, usually when complaints or pain are present. Informat...

  • Systematic Review
  • Open Access
2 Citations
3,553 Views
21 Pages

Navigation Support during Transitions in Care for Persons with Complex Care Needs: A Systematic Review

  • Lyndsay Howitt,
  • Greeshma Jacob,
  • Giulia Zucal,
  • Judy Smith,
  • Rhonda Crocker Ellacott and
  • Shirlee Sharkey

10 September 2024

Persons with complex care needs that arise due to chronic health conditions, serious illness, or social vulnerability are at increased risk of adverse health outcomes during transitions in care. To inform the development of a best practice guideline,...

  • Review
  • Open Access
2 Citations
3,213 Views
17 Pages

A Gastroenterologist’s Guide to Care Transitions in Cystic Fibrosis from Pediatrics to Adult Care

  • Dhiren Patel,
  • Michelle Baliss,
  • Pavithra Saikumar,
  • Laith Numan,
  • Jeffrey Teckman and
  • Christine Hachem

30 October 2023

Cystic Fibrosis is a chronic disease affecting multiple systems, including the GI tract. Clinical manifestation in patients can start as early as infancy and vary across different age groups. With the advent of new, highly effective modulators, the l...

  • Article
  • Open Access
7 Citations
3,211 Views
14 Pages

19 December 2021

Transitioning survivorship care from oncologists to primary care physicians (PCPs) is a reasonable alternative to oncologist-led care. This study assessed oncologists’ attitudes and beliefs regarding sharing/transitioning survivorship care. A p...

  • Brief Report
  • Open Access
4 Citations
3,538 Views
10 Pages

Key Care Provision Aspects That Affect Care Transition in the Long-Term Care Systems: Preliminary Review Findings

  • Estera Wieczorek,
  • Ewa Kocot,
  • Silvia Evers,
  • Christoph Sowada and
  • Milena Pavlova

The aim of this brief report is to present the protocol and preliminary findings of a systematic review on key aspects of care provision that affect care transition of older adults 60+ within the long-term care systems. This brief report describes an...

  • Communication
  • Open Access
3 Citations
3,215 Views
6 Pages

Evolution of Interdisciplinary Transition of Care Services in a Primary Care Organization

  • William J. Hitch,
  • Irene Park Ulrich,
  • Anne C. Warren,
  • Dow Stick,
  • Danielle Leyonmark and
  • Mackenzie Farrar

3 December 2019

Transitions of care create complex management challenges for providers and leave patients vulnerable to medication errors and hospital readmissions. This article examines the evolution of an interdisciplinary team of pharmacists and nurse care manage...

  • Article
  • Open Access
2 Citations
2,682 Views
9 Pages

Assessing the Impact of an Advanced Clinical Decision Support System on Medication Safety and Hospital Readmissions in an Innovative Transitional Care Model: A Pilot Study

  • Jennifer M. Bingham,
  • Lindsey Baugham,
  • Andriana Hilaneh,
  • Karley Tranchina,
  • Daniel Arku,
  • Becka Eckert,
  • Nicole Scovis and
  • Jacques Turgeon

7 April 2022

(1) Background: Adverse drug events and inappropriate use of medications lead to hospitalizations, medication-related morbidity, and mortality. This study examined whether a novel medication risk prediction tool, the MedWise Risk Score™, was as...

  • Study Protocol
  • Open Access
1 Citations
3,367 Views
13 Pages

Study Protocol for a Hospital-to-Home Transitional Care for Older Adults Hospitalized with Chronic Obstructive Pulmonary Disease in South Korea: A Randomized Controlled Trial

  • Heui-Sug Jo,
  • Woo-Jin Kim,
  • Yukyung Park,
  • Yu-Seong Hwang,
  • Seon-Sook Han,
  • Yeon-Jeong Heo,
  • Dahye Moon,
  • Su-Kyoung Kim and
  • Chang-Youl Lee

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory condition characterized by persistent inflammation in the airways, resulting in narrowing and obstruction of the air passages. The development of COPD is primarily attributed t...

  • Review
  • Open Access
8 Citations
3,763 Views
9 Pages

17 February 2021

The transition from pediatric to adult health care is a challenging yet important process in rheumatology as most childhood-onset rheumatic diseases persist into adulthood. Numerous reports on unmet needs as well as evidence of negative impact from p...

  • Article
  • Open Access
3 Citations
2,528 Views
8 Pages

Optimizing Cancer Survivorship Care: Examination of Factors Associated with Transition to Primary Care

  • Som. D. Mukherjee,
  • Daryl Bainbridge,
  • Christopher Hillis and
  • Jonathan Sussman

24 February 2023

Healthcare systems in Canada and elsewhere have identified the need to develop methods to effectively and safely transition appropriate cancer survivors to primary care. It is generally accepted that survivors with a low risk of adverse events, inclu...

  • Article
  • Open Access
58 Citations
62,275 Views
14 Pages

27 January 2023

Healthcare professionals often feel challenged by complex patients and the associated care needs during care transition. Interprofessional collaboration (IPC) is considered an effective approach in such situations. However, a fragmented healthcare sy...

  • Article
  • Open Access
1,312 Views
14 Pages

Quality of Transition of Care from Hospital to Home for Patients Hospitalized for COVID-19

  • Edna Ribeiro de Jesus,
  • Julia Estela Willrich Boell,
  • Michelle Mariah Malkiewiez,
  • Marinalda Boneli da Silva,
  • Greici Capellari Fabrizzio,
  • Catiele Raquel Schmidt,
  • Luana Amaral Alpirez,
  • Darlisom Sousa Ferreira and
  • Elisiane Lorenzini

7 April 2025

Objective: To measure the quality of the transition of care for COVID-19 patients after discharge from hospital to home. Method: A cross-sectional, prospective study carried out in a hospital in Santa Catarina, with 201 patients hospitalized for COVI...

  • Article
  • Open Access
1 Citations
1,730 Views
12 Pages

30 January 2024

Objective: People with variations in sex characteristics (VSCs) have been receiving inadequate care for many decades. The Chicago consensus statement in 2006 aimed to introduce improved comprehensive care, which would include the transition of care f...

  • Review
  • Open Access
8 Citations
6,286 Views
13 Pages

Transition to Adult Care for Obstructive Sleep Apnea

  • Austin Heffernan,
  • Uzair Malik,
  • Russell Cheng,
  • Shaun Yo,
  • Indra Narang and
  • Clodagh M. Ryan

2 December 2019

Obstructive sleep apnea may occur throughout the lifespan, with peak occurrences in early childhood and during middle and older age. Onset in childhood is overwhelmingly due to adeno-tonsillar hypertrophy, while in adulthood, contributors include ris...

  • Communication
  • Open Access
9 Citations
5,134 Views
12 Pages

Advancing Pharmacy Practice through an Innovative Ambulatory Care Transitions Program at an Academic Medical Center

  • Jamie Cavanaugh,
  • Nicole Pinelli,
  • Stephen Eckel,
  • Mark Gwynne,
  • Rowell Daniels and
  • Emily M. Hawes

Hospital readmissions are common and often preventable, leading to unnecessary burden on patients, families, and the health care system. The purpose of this descriptive communication is to share the impact of an interdisciplinary, outpatient clinic-b...

  • Review
  • Open Access
3 Citations
2,847 Views
10 Pages

Transition to Adulthood in Pediatric Palliative Care: A Narrative Review

  • Franca Benini,
  • Laura Brogelli,
  • Anna Mercante and
  • Luca Giacomelli

16 July 2024

Pediatric palliative care (PPC) is defined as “the active care of the child’s body, quality of life, mind and spirit, also giving support to the family”. PPC should be established once a diagnosis of life-limiting or life-threatenin...

  • Article
  • Open Access
4 Citations
1,530 Views
7 Pages

Resources of Residents for Potential Transition from Long-Term Care to Community

  • Lina Spirgienė,
  • Pirkko Elina Routasalo and
  • Jūratė Macijauskienė

4 January 2014

Background and Objective. Transition from long-term care to the community can have positive effects on residents’ health and quality of life and promote the feelings of happiness, safety, and independence. The aim of this study was to examine residen...

  • Article
  • Open Access
1,255 Views
16 Pages

Facilitating and Hindering Factors in the Implementation of a Care Transition Strategy: Mixed Methods Study

  • Marcia Baiocchi Amaral Danielle,
  • Elisiane Lorenzini,
  • Ana Letícia Missio de Oliveira,
  • Anthony John Onwuegbuzie,
  • Letícia Flores Trindade,
  • Michelle Mariah Malkiewiez,
  • Darlisom Sousa Ferreira,
  • Luana Amaral Alpirez and
  • Adriane Cristina Bernat Kolankiewicz

Objective: To identify facilitating and hindering factors for implementing a care transition strategy for adult patients undergoing elective colorectal cancer surgery, within a primary health care (PHC) context, addressing gaps in the literature on i...

  • Article
  • Open Access
6 Citations
2,341 Views
13 Pages

22 August 2024

Care transitions from hospital to home for older adults with malnutrition present a period of elevated risk; however, minimal data exist describing the existing practice. This study aimed to describe the transition of nutrition care processes provide...

  • Article
  • Open Access
5 Citations
2,719 Views
7 Pages

Background: Prader–Willi syndrome (PWS) is a rare, neurodevelopmental, genetic disease caused by the lack of expression of paternal genes in chromosome 15. The typical characteristics, including hyperphagia, muscular hypotonia, abnormal body composit...

  • Article
  • Open Access
3 Citations
3,269 Views
14 Pages

In a future where home health care is no longer an information silo, patient information will be communicated along transitions in care to improve care. Evidence-based practice in the United States supports home health care patients to see their prim...

  • Review
  • Open Access
6 Citations
3,916 Views
14 Pages

24 May 2025

Background: Limited information exists regarding the current practice of transitioning from enteral nutrition (EN) to oral nutrition (ON) and the effect of this process on the relationship between energy and protein requirement, provision, and nutrit...

  • Review
  • Open Access
203 Views
13 Pages

Background: Continuity of care is a core component of high-quality, patient-centered health systems and a central domain of nursing practice, particularly for older adults and people living with chronic and complex conditions. Yet discontinuities rem...

  • Review
  • Open Access
2,177 Views
17 Pages

Objective: This narrative review aims to synthesize qualitative research on the experiences of patients, families, and healthcare professionals during the transition of advanced cancer patients from hospital to community care. Methods: A systematic s...

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