Transitional care models: preventing readmissions for high-risk patient populations.

Transition from hospital to home is a vulnerable period for older adults with multiple chronic conditions. A pilot of the Transitional Care Model at a community hospital reduced readmission rates for patients with heart failure by 48%. This article shares the experience of a large metropolitan health care system in expanding transitional care across facilities to decrease readmission rates.

Differences in end-of-life preferences between congestive heart failure and dementia in a medical house calls program.

Objectives: To compare end-of-life preferences in elderly individuals with dementia and congestive heart failure (CHF).

Design: Retrospective case-control study.

Setting: Geriatrician-led interdisciplinary house-call program using an electronic medical record.