Transitioning patients from one health care setting to another can be risky to the patient and could lead to other hospitalizations or complications if issues concerning the patient’s care are not clearly communicated to the patient and the entire care team.  

Also, despite growing evidence that certain models of care transition successfully reduce readmission or emergency department visit rates after discharge, hospitals and communities are still challenged with identifying what specific components or strategies to implement.

To meet these challenges, the Patient-Centered Outcomes Research Institute (PCORI) has launched the Transitional Care Evidence to Action Network. Westat is supporting this work.

The Network is

• Promoting information sharing and collaborating among research teams working on 21 different health studies by organizing online and in-person meetings
• Developing a website to share best practices and lessons learned from the research teams, patient partners, and other stakeholders
• Establishing links between the teams and clinicians, policymakers, health system leaders, and patient groups who may find the results helpful for making health care decisions
• Providing support to the research teams by helping assess factors such as
  • Social determinants of health
  • Health care system quality
  • Access to care
  • Patients’ medical risk factors that affect study results

The Network will enhance current research by

• Engaging stakeholders and end-users
• Preparing research findings, best practices, and tools for dissemination
• Helping researchers turn research results into programs and policies to improve care transitions