Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence

"Received the following Transitional Care strategies:~1. Helpful Health Care Contact OR Symptom Management~2. Post-discharge Care Consultation~3. Patient Goal/Preference Assessment~4. Plain Language Communication in Hospital~5. Plain Language Communication at Home~6. Transition Summary for Patients and Family Caregivers"

"Received the following Transitional Care Strategies:~1. Transition Team~2. Home visits~3. Plain Language Communication at Home~4. Promote Trust at Home~5. Referral to Community Services~6. Follow-up Appointment"

"Received the following Transitional Care Strategies:~1. Post-discharge care consultation~2. Identify High-Risk Patients and Intervene~3. Medication Reconciliation~4. Plain Language Communication in Hospital~5. Promote Trust in the Hospital~6. Transition Summary for Patients and Family Caregivers"

"Received the following Transitional Care Strategies:~1. Patient Goal/Preference Assessment~2. Identify High-Risk Patients and Intervene~3. Timely Exchange of Critical Patient Information among Providers~4. Patient/Family Caregiver Transitional Care Needs Assessment"

"Received the following Transitional Care Strategies:~1. Post-discharge care consultation~2. Language Assessment~3. Teach Back for Information and Skills"

No specific Transitional Care Strategy