Under the Affordable Care Act of 2010, a variety of transitional care programs and services have been established to improve quality and reduce costs. These programs help hospitalized patients with complex chronic conditions-often the most vulnerable-transfer in a safe and timely manner from one level of care to another or from one type of care setting to another. We conducted a systematic review of the research literature and summarized twenty-one randomized clinical trials of transitional care interventions targeting chronically ill adults. We identified nine interventions that demonstrated positive effects on measures related to hospital readmissions-a key focus of health reform. Most of the interventions led to reductions in readmissions through at least thirty days after discharge. Many of the successful interventions shared similar features, such as assigning a nurse as the clinical manager or leader of care and including in-person home visits to discharged patients. Based on these findings, we recommend several strategies to guide the implementation of transitional care under the Affordable Care Act, such as encouraging the adoption of the most effective interventions through such programs as the Community-Based Care Transitions Program and Medicare shared savings and payment bundling experiments.

Nurse practitioners are the principal group of advanced-practice nurses delivering primary care in the United States. We reviewed the current and projected nurse practitioner workforce, and we summarize the available evidence of their contributions to improving primary care and reducing more costly health resource use. We recommend that nurse practice acts--the state laws governing how nurses may practice--be standardized, that equivalent reimbursement be paid for comparable services regardless of practitioner, and that performance results be publicly reported to maximize the high-quality care that nurse practitioners provide.

Across the outcomes studied, results suggest that NP and PA care were largely comparable to PCMD care in HCs.

The combined results have important practical implications for other, subsequent translational efforts and for assisting providers, policy makers, payers, and other change agents in integrating evidence-based practice with "real world" management.

Elderly long-term care recipients who require acute hospitalizations must navigate a fragmented system with poor "handoffs," often resulting in negative outcomes. This article makes the case that reducing preventable hospitalizations and improving transitions to and from hospitals will enhance health care quality and outcomes among these elders. Immediate action targeting diffusion of evidence-based care is recommended to decrease avoidable rehospitalizations and achieve cost savings. Policy changes are needed to address barriers to high-quality transitional care, including deficits in health professionals' and caregivers' knowledge and resources, regulatory obstacles, and inadequate financial incentives and clinical information systems.