Topic Spotlight

Transitional Care 

Through its Transitional Care Evidence to Action Network (TC-E2AN), PCORI-funded research teams facilitate collaborative learning and share lessons learned in conducting patient-centered research on transitional care. The overarching goal of the network is to produce actionable and relevant evidence to indicate which approaches to transitional care are most effective in specific populations, and ultimately to improve delivery of transitional care services.

PCORI Answers Critical Questions

PCORI funds studies to help patients and those who care for them answer a range of questions about transitional care, such as:

What are the experiences of individuals with multiple chronic health conditions who transition from a hospital back to a rural community?

How can the healthcare system help me take care of my health at home without returning to the emergency department?

Which transitional care components are most effective in addressing the needs, preferences, and values of diverse populations in a variety of settings?

Study Results that Support Better-Informed Decisions

Patient-Centered Program Improves Care Transitions for Patients with COPD

Compared to standard hospital discharge care, BREATHE—a program that offers tailored care support and disease self-management education—helped more patients with chronic obstructive pulmonary disease (COPD) avoid readmission after discharge, the BREATHE study found. The program also led to better health outcomes six months after discharge, per results published in JAMA.

Making or Breaking Recovery Through Care Transitions

The first phase of Project ACHIEVE, published in the Annals of Family Medicine, determined that patients and their caregivers facing a transition from a hospital to their home most want to feel prepared and capable of applying care plans, to receive unambiguous accountability from the healthcare system, and to feel that medical providers care for and about them.

Addressing Transitional Care Challenges

Hear about how PCORI-supported projects are addressing challenges in ways other research has not, and why transitional care is an important study area.

The PCORI Approach to Transitional Care

Why Study Transitional Care

Transitional Care Portfolio Snapshots

Hospital to Home (16) Hospital to Rehab (3) ED to Home (1) Outpatient Specialty Care to Hospital (1)

Projects by Patient Transition Setting

Transitional Care Projects We've Funded: By Condition/Disease: CVD ($22.2M) Non-Disease Specific ($18.9M) Trauma/Injury ($15.9M)

Projects by Condition Type