Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention. Executive Summary. Evidence Report/Technology Assessment Number 202

摘要

The Centers for Medicare & Medicaid Services, the National Quality Forum, and the Institute of Medicine have identified improved transitions in care as priorities for demonstration projects and research to reduce rehospitalizations and improve the quality of postdischarge care. Despite advances in the quality of acute-care management of stroke and myocardial infarction (MI), there are gaps in knowledge about effective interventions to better manage the transition of care for patients with these complex health conditions. Transition of care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location, and is often provided by interdisciplinary teams of professionals. Indicators of potential transition problems include avoidable rehospitalizations and emergency room visits as well as poor functional status and quality of life.