setting - often a sub-acute nursing facility, a rehabilitation facility, or home either with or without professional homecare services. Adverse patient outcomes include continuation or recurrence of symptoms, temporary or permanent disability, and death.

Healthcare utilization outcomes for patients experiencing poor transitional care include returning to the emergency room or being admitted to the hospital. As healthcare expenditures rise at an unsustainable rate, there is increasing focus by patients, providers, and policymakers on restraining