Transitional care programs such as this have typically
not been adopted because of lack of Medicare reimbursement,
the absence of effective marketing forces, the
challenges such care present to the culture of current
medical practice, which is characterized by the organization
of care into distinct and separate silos (i.e., hospital and
home care), and limited meaningful longitudinal integration
of physician and nursing care to support patients’ needs
throughout an acute episode of illness.
Although further research is required to define the
relative effectiveness and cost effectiveness of alternative
intervention designs and components, to define the optimal
length and intensity of interventions, and to further
examine the generalizability of findings across a broader
spectrum of geographic and care settings, the clinical and
economic effectiveness of these interventions support the
value of their more widespread use.