Narrative Review: Integrated Transitional Care Models for High-Utilizer Patients with Complex Chronic Conditions: A Multidisciplinary Synthesis
Abstract
Background: A small subset of patients with complex chronic conditions, such as heart failure (CHF), chronic obstructive pulmonary disease (COPD), and diabetes with complications, account for a disproportionately high share of emergency department (ED) visits and hospital readmissions. This pattern of high utilization signifies fragmented care, patient distress, and unsustainable system costs, highlighting an urgent need for effective transitional care models. Aim: This narrative review aims to examine the integrated, multidisciplinary care models designed to improve the transition of care for high-utilizer patients, with a focus on preventing recurrent acute care encounters. Methods: A comprehensive search of PubMed, CINAHL, and Web of Science databases was conducted for peer-reviewed literature (2010-2024) addressing interventions involving public health, EMS, nursing, pharmacy, and laboratory/radiology within transitional care frameworks. Results: Evidence robustly supports that coordinated interventions—particularly nurse-led transition coaching, pharmacist-led medication management, and community paramedicine—significantly reduce readmissions and ED visits. Success is contingent on proactive identification of high-risk patients, interprofessional communication, and addressing social determinants of health (SDOH). Interventions that merely provide information without intensive, relationship-based support show limited effectiveness. Conclusion: Breaking the "revolving door" cycle requires moving beyond siloed care to implement proactive, patient-centered models that integrate clinical management with social support. Future efforts must standardize outcome measures, leverage health information technology for real-time data sharing, and advocate for sustainable payment models that reward care coordination and improved patient outcomes
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Copyright (c) 2024 Abdullah Abdulaziz Ibrahim Alghamdi, Turki Mohammad Ali Khawaji, Rami Redha Abdulrasheed Ambon, Jaber Mufareh Ali Al Huraysi, Dalia Sami Dabash, Mohammed Munis R Alhadhrami, Hesham Yahya Ali Hakami, Amna Obaid Abdo Abu Ayed, Mohammed Hussain Mohammed Alqahtani, Abdullah Mohsen Alotaibi, Abdullah Abdura Hassan Almaleki, Saadi Mousa Alshammari
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