Hospital-community partnerships to aid transitions for older adults: applying the care transitions framework.

This study examined the implementation and hospital-wide scaling of a community-based transitional care program to reduce readmissions among adults 65 years or older.

Our analysis was guided by the Care Transitions Framework and was based on semistructured interviews with program implementers to identify intervention successes, barriers, and outcomes beyond reducing readmissions.

Such outcomes included the program's critical role in providing a safety net and transition to more advanced care, and redefining intervention success from more patient-centered perspectives.