Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care

Audris D. Smith, Judith Treschuk
  • Home Health Care Management & Practice, March 2018, SAGE Publications
  • DOI: 10.1177/1084822318765737

Transitional Care in Home Health Care

What is it about?

Transitional care is patient care coordination between provider settings. This study shows how communication and coordination occurs when patient transitions occur between the acute or sub-acute setting into home health care using a specific transitional care model's intervention.

Why is it important?

Our findings revealed year-over-year improvements in quality indicators for reducing patient re-hospitalizations, unplanned emergency room use, patient medication education, and patient medication administration.


Audris Smith (Author)
Ashford University

I hope this article will help leaders develop strategic tactics to improve partnership collaborations and communications between their interdisciplinary team to improve patient outcomes. Moreover, I hope this article could lead to replicable care transition processes that could be shared throughout the health care industry

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