Introduction Care coordination reduces care fragmentation and costs while improving health care quality. Transitional care programs, guided by tested models are an important component of effective care coordination, and have been found to reduce adverse events and prevent hospital readmissions. Using the Care Coordination Atlas as a framework, this article reports an integrative review of two transitional care models including analysis of model components, implementation factors, and associated 30-day all-cause hospital readmission rates. Methods Integrative review methodology. PubMed and Scopus databases were searched from January 2015 to July 2020. Fourteen studies set in 18 skilled nursing facilities and 50 hospitals were selected for data extraction and analysis. Results The ReEngineered Discharge model had five components and the Better Outcomes by Optimizing Safe Transitions model had eight components in the nine Care Coordination Atlas domains. Communication dominated activities in both models while neither addressed accountability/responsibility. Implementation was influenced by leadership commitment to understanding complexity of the models, culture change, integration of models into workflows, and associated labor costs. Model implementation studies consistently reported improvements in facilities’ 30-day all-cause hospital readmission rates. Discussion The Care Coordination Atlas was a useful framework to guide analysis of transitional care models. Leadership commitment to and participation in model implementation is vital. The models do not focus beyond the immediate post-discharge period limiting the impact on chronic disease management. Frameworks such as the Care Coordination Atlas are useful to help guide development of care coordination activities and associations with readmission rates.

Care of adults with Autism Spectrum Disorder (ASD) is a public health priority and costs are projected to be 549 billion US dollars by 2025. Middle and older adult FCGs of adults with ASD often provide lifelong care, experience chronic stress, consequently, are at risk of poor mental health and QOL. An integrative review examined factors associated with resilience in studies of middle and older adult FCGs of adults with ASD. A comprehensive literature search found 10 reports of 8 studies published in peer-reviewed scholarly journals before October 13, 2020. Studies and/or reports of factors associated with resilience in middle and older adult FCGs of adults with ASD were examined using PRISMA, and quality checklists. Some 340 articles met search criteria, 14 were fully reviewed, and 10 were included. Findings suggest FCGs of adults with ASD show capacity for resilience consistent with research on FCGs of children with ASD significant chronic stress. A broad range of resilience factors were studied, and resilience was associated with positive social support, higher QOL, self-efficacy, and problem and meaning-focused coping styles. There is a dearth of research on middle and older adult FCGs of adults with ASD. Increased reporting of social determinants of health and participation of underrepresented groups is needed. Future research must address FGC heterogeneity and specify theoretically grounded conceptual and operational definitions of resilience. Identifying resilience factors is necessary for intervention studies to enhance resilience.