Introduction: Millions of people worldwide have complex health and social care needs. Care
coordination for these patients is a core dimension of integrated care and a key …

Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic and treatment
process that identifies medical, psychosocial, and functional capabilities of older adults to …

Background There is widespread interest in programs aiming to reduce spending and
improve health care quality among “superutilizers,” patients with very high use of health care …

Background: Nearly 25% of patients hospitalized with heart failure (HF) are readmitted
within 30 days. Purpose: To assess the efficacy, comparative effectiveness, and harms of …

Importance Health care services that support the hospital-to-home transition can improve
outcomes in patients with heart failure (HF). Objective To test the effectiveness of the Patient …

Transitional care (TC) has received widespread attention from researchers, health system
leaders, clinicians, and policy makers as they attempt to improve health outcomes and …

Transitional care interventions aim to improve care transitions from hospital to home and to
reduce hospital readmissions for chronically ill patients. The objective of our study was to …

Background Provision of high quality transitional care is a challenge for health care
providers in many western countries. This systematic review was conducted to (1) identify …

In patients with heart failure (HF), use of 30-day rehospitalization as a healthcare metric and
increased pressure to provide value-based care compel healthcare providers to improve …

Background Demographic changes are taking place in most industrialized countries.
Geriatric patients are defined by the European Union of Medical Specialists as aged over 65 …