Presidium Health White Paper · July 2026

Matching Transitional Care to Patient Risk

A comparative review of clinical models, context, and longitudinal accountability—and a proposed framework for matching transition support to the patient’s dominant risks, receiving environment, and need for continuing ownership.

Ashkan Hayatdavoudi, MD, Esq.; Melody Shedlosky, RN, MBA; and Pouya Afshar, MD, MBA Presidium Health Corp., San Diego, California

Download the White Paper Open PDF in a New Tab

Executive overview

Transitional care is not a uniform post-discharge product

Transitions between hospitals, skilled nursing facilities, outpatient care, community services, and home expose patients to medication discrepancies, incomplete information transfer, delayed follow-up, functional decline, caregiver strain, and avoidable acute-care use.

Major models address different failure mechanisms. BOOST and Project RED strengthen discharge reliability. The Care Transitions Intervention develops patient and caregiver capacity. The Transitional Care Model provides sustained clinical continuity. Pharmacist-led programs target medication risk, while navigation and health-social models address access and social barriers.

The evidence does not support a universal hierarchy in which one model consistently outperforms all others. Value depends on the fit among the intervention’s mechanism, patient risk, caregiver capacity, receiving setting, local infrastructure, and required duration of support.

Key findings

What the evidence suggests

Universal safety functions remain essential

Medication reconciliation, patient and caregiver preparation, information transfer, accepted responsibility, follow-up planning, and escalation instructions should form the baseline for every transition.

Additional care should target the dominant risk

Coaching, pharmacy, navigation, disease-specific pathways, and sustained clinical management address different problems and should not be treated as interchangeable products.

Duration should be based on readiness—not the calendar

Time-limited intervention should end when medication, follow-up, symptoms, services, social needs, responsibility, and escalation pathways are sufficiently stable.

Relationships and accountability may be active mechanisms

Patients and caregivers value continuity, clear ownership, caring relationships, and fewer unnecessary handoffs. Relational continuity may support engagement, trust, and execution of the care plan.

Context is part of the intervention

Skilled nursing capability, caregiver readiness, social conditions, rural distance, workforce continuity, transportation, technology, and governance affect whether a model can be delivered as intended.

Payment should support—but not define—the clinical model

Routine payment, case or episode funding, prospective capacity support, and quality incentives may each have a role. Financing must reflect who incurs costs, who captures savings, and who remains accountable.

Proposed framework

A risk-matched architecture for transitional care

The proposed framework combines a universal transition standard, multidomain risk assessment, targeted transitional intervention, and longitudinal stabilization for patients whose vulnerability persists across acute events.

Risk-matched transitional-care architecture showing a universal transition standard, multidomain risk assessment, return to capable routine care, risk-targeted transitional care, longitudinal stabilization, and cross-cutting accountability requirements. — Figure 1. Risk-matched architecture for transitional care Evidence-supported mechanisms are organized within a synthesis-derived three-tier framework. An acute event triggers reassessment of risk and care intensity without automatically transferring ownership to another temporary program.

Transition pathway

Where transitions fail—and what continuity must bridge

Transitional failures occur within settings and at the boundaries between them. A safe handoff requires more than sending information: the receiving organization must be capable of acting on the plan, responsibility must be accepted, and the patient and caregiver must be able to carry out the next steps.

Hospital, skilled nursing and post-acute care, home and community, and primary or longitudinal care pathway showing common failure points and the patient, relational, rural, social, and accountability factors that must bridge each handoff. — Figure 2. Where transitions fail—and what continuity must bridge Common failure points and cross-cutting constraints synthesized from hospital-to-SNF, SNF-to-home, rural, patient and caregiver, and relationship-based evidence.

Review approach

Comparative integrative narrative review

Evidence base

Trials, systematic and scoping reviews, economic evaluations, qualitative studies, implementation reports, and policy analyses.

Search approach

An author-curated full-text collection supplemented by gap-directed PubMed/MEDLINE and targeted publisher, government, and professional-organization searches conducted July 18–19, 2026.

Interpretation

Evidence was compared by mechanism, workforce, intensity, duration, setting, population fit, implementation requirements, outcomes, and economic perspective.

This was an iterative, gap-directed narrative review rather than a formal systematic review. It did not use duplicate independent screening, a PRISMA process, or comprehensive searches of every bibliographic database.

Funding and disclosures

This work was funded by Presidium Health Corp., the authors’ employer. All authors are employees and executive officers of Presidium Health. Presidium Health holds multiple contracts to provide transitions-of-care and related care-management services. These professional and financial interests could be perceived as influencing interpretation of the evidence and the proposed framework.

Read the complete white paper

Download the full report for the comparative model review, four evidence tables, proposed three-tier framework, economic and payment discussion, research agenda, and complete 31-source bibliography.

Download PDF

Questions about this white paper: info@presidiumhealth.com