Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial

By M. Naylor, D. Brooten, Roberta L. Campbell, G. Maislin, K. McCauley, J. Schwartz. Journal of The American Geriatrics Society, 2004

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Patient race, site of care, and 30-day readmission rates among elderly Americans (2011, neutral): “Comorbidities Diabetes without complications 12 530 (30) 119 344 (22) 50 954 (34) 311 741 (26) 24 196 (29) 231 498 (20)”
The care span: The importance of transitional care in achieving health reform. (2011, neutral): “…Disease/case managementa NS —b —b • Jack et al., 2009 Discharge management plus follow-up • —b —b • Naylor et al., 2004 Discharge management plus follow-upa NS • • •c Naylor et al., 1999 Discharge management plus follow-upa NS —b NS •c Naylor et al., 1994 Discharge management plus follow-up NS…”
Coordinating care--a perilous journey through the health care system. (2008, background): “His wor k on transitions, buttressed by the studies of Mary Naylor and others [ 72 ], goes well beyond a lim ited intervention based on one small research study and transcends all the protocols and check lists that have been developed for coordinating care.”