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Transitional Care Programs: Study Design Phase

Literature Review

The roles and responsibilities of healthcare specialists vary depending on their fields of expertise, the number of years in the profession, available equipment, and other factors. Patients who need professional and timely help may misunderstand the aspects of work of some healthcare providers, which highlights the importance of proper strategies for care transitions. Transitional care is defined as a range of services helping to “ensure healthcare continuity” and “promote the timely transfer of patients from one level of care to another” (Donald et al., 2015, p. 437). The role of transitional care programs in the reduction of readmission rates is widely discussed by modern researchers with reference to specific fields of medicine.

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The cases of early readmissions are strictly interconnected with the quality of care and the effectiveness of collaboration among healthcare professionals. Proper interventions aimed at making readmissions less common should be designed with reference to the volume of care and other quality indicators.

Numerous studies that appeared between 2008 and 2013 report that shorter periods of hospital care are interconnected with readmission rates, the frequency of post-discharge suicides, and drug addiction (Botha, Coetzee, Koen, & Niehaus, 2018). Readmission-reducing programs can be more effective if they are based on the analysis of post-discharge risk factors for patients connected with the amount of care.

High readmission rates in patients with chronic and acute conditions are indicative of problems with healthcare quality and patient education. In addition to that, they become a financial burden for hospitals due to readmission penalties and costs (Feltner et al., 2014). Programs helping to reduce hospital readmissions are not standardized, but they usually focus on “patient or caregiver education, medication reconciliation, and provider coordination” (Feltner et al., 2014, p. 774).

In their systematic review, Feltner et al. (2014) organize the existing knowledge and single out five types of transitional interventions commonly used in cardiology. They include programs that involve “home visits by clinicians,” Science-Technology-Society (STS) interventions based on post-discharge phone calls, telemonitoring techniques, “outpatient clinic-based” services, and self-care training (Feltner et al., 2014, p. 775). The mentioned interventions are different in terms of their practical effectiveness. For instance, the review concludes that STS and home visits successfully reduce readmission and mortality rates in heart failure patients (Feltner et al., 2014).

These learnings run counter to the conclusions of Botha et al. (2018), who find telephone-based interventions ineffective for the reduction of readmissions. Taking into account that the approaches have different advantages, some researchers aim to unite them into comprehensive programs in order to maximize positive outcomes for patients and healthcare institutions (Rubin, 2015). The creation of effective programs requires an understanding of the medical field and patients’ physical and psychological needs.

Successful transitioning interventions usually involve the collaboration of a great number of specialists. The study by Akerele et al. (2017) discusses the implementation of a transitional care intervention that is based on three techniques. This intervention involves the use of a “warm hand-off” strategy, the provision of medications on the day of discharge, and phone calls to patients and aftercare programs (Akerele et al., 2017, p. 170).

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By combining the techniques above, healthcare providers managed to reduce readmission rates in psychiatric units by almost 30 percent and avoided additional costs (Akerele et al., 2017). It is possible to suggest that complex transitional care interventions are more effective if compared to ones utilizing a smaller number of techniques.

Methodology and Research Design

The planned research will be devoted to ways to reduce or eliminate hospital readmissions of chronically ill patients. It is known that patients with such conditions as diabetes have increased risks of early readmissions due to the associations between the disease prevalence and lower-income levels (Rubin, 2015). The study will focus on this group and other chronically ill people to analyze the effectiveness of techniques reducing readmissions.

As for the design, the proposed study is aimed at generalizing on the effective care transition interventions helping to eliminate readmissions. Taking into account that such techniques are numerous, testing their effectiveness in actual experiments would require significant financial expenses and the creation of research teams. The planned study is a systematic quantitative review that analyzes the results of randomized controlled trials and other reviews devoted to the topic.

The research process will include a series of important stages to ensure credible results. At first, it will be necessary to formulate the key question and make a list of relevant search queries. In the case being discussed, attention is paid to nurse-led transitional interventions and readmission rates in chronically ill. Search queries used in various combinations can include “readmission reduction programs”, “chronic disease”, “nursing interventions”, “transitions of care”, etc.

Secondly, it will be necessary to design inclusion criteria to ensure that all analyzed studies are relevant to the topic and methodologically accurate. Consideration will be given to the hierarchy of evidence to provide reliable results. The following inclusion criteria will be used to select relevant articles:

  • The type of study (RCTs, systematic reviews of RCTs, meta-analytical studies);
  • The type of source (peer-reviewed articles);
  • The selection of population (adult patients with chronic illnesses).

During the next step, the researchers will search for studies utilizing the aforementioned search queries and specialized databases for healthcare professionals. The results will be thoroughly checked to exclude all duplicates. The inclusion criteria will be used to conduct a more detailed analysis and get rid of irrelevant or low-quality studies. As the range of relevant studies is defined, it will be necessary to present the data in a well-organized way. The aspects being summarized are the type of study, the detailed description of all tested interventions, the summary of patient characteristics, and the measurable, practical effects of programs.

The data will be divided into groups based on the type of tested interventions, and all groups will be compared with reference to the documented effectiveness of programs and the quality of evidence. Based on the results, a comprehensive readmission reduction strategy will be designed and thoroughly described. The flowchart demonstrating the planned research process is presented below.

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The planned research process.
Fig.1. The planned research process.

Sampling and Tools

The study being discussed will focus on reviewing the relevant findings reported by previous researchers in the field. With that in mind, it is planned to utilize a non-probability sampling technique such as purposive sampling. The inclusion criteria and suggested search queries discussed in the previous section will help ensure the reliability of conclusions. Although the use of this sampling technique is believed to increase the risks of cognitive mistakes, it would be beneficial for the planned study due to the objectivity of the inclusion criteria.

To conduct the planned study, it will be pivotal to use a range of tools for data collection and analysis. For instance, the selection of studies will be conducted with the help of the following online search tools: Medline, PubMed, Science Direct, and EBSCO. In addition to ensuring access to these databases, the use of specialized software for literature reviews will be required. Popular tools such as Distiller SR or Meta-Disc can be used to make informed conclusions about nursing interventions that help ensure better patient outcomes for chronically ill people and reduce the risks of readmissions.


Akerele, E., Lim, C., Olupona, T., Ojo, O., Co, N., & Lim, J. J. (2017). Reducing readmission rates in inpatient settings. International Journal of Mental Health, 46(3), 168-176.

Botha, U. A., Coetzee, M., Koen, L., & Niehaus, D. J. (2018). An attempt to stem the tide: Exploring the effect of a 90-day transitional care intervention on readmissions to an acute male psychiatric unit in South Africa. Archives of Psychiatric Nursing, 32(3), 384-389.

Donald, F., Kilpatrick, K., Reid, K., Carter, N., Bryant-Lukosius, D., Martin-Misener, R.,… DiCenso, A. (2015). Hospital to community transitional care by nurse practitioners: A systematic review of cost-effectiveness. International Journal of Nursing Studies, 52(1), 436-451.

Feltner, C., Jones, C. D., Cené, C. W., Zheng, Z. J., Sueta, C. A., Coker-Schwimmer, E. J.,… Jonas, D. E. (2014). Transitional care interventions to prevent readmissions for persons with heart failure: A systematic review and meta-analysis. Annals of Internal Medicine, 160(11), 774-784.

Rubin, D. J. (2015). Hospital readmission of patients with diabetes. Current Diabetes Reports, 15(4), 17. Web.

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