Transitional care for older adults: a cost-effective model.

Although the quality of care in hospitals and ambulatory settings is undergoing more scrutiny, far less attention has focused on the care patients receive as they move from one setting to another. Older patients who transition from hospital to home are particularly vulnerable: many of these patients have multiple health problems that continue beyond discharge. In response, investigators at the University of Pennsylvania developed a model of care delivered by nurse experts who follow vulnerable elders though their hospitalization and monitor their progress at home. This Issue Brief summarizes more than a decade of research on this model of transitional care and its effects on the costs and quality of care for hospitalized elderly patients.