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Effectiveness and cost of a transitional care program for heart failure: a prospective study with concurrent controls.
Stauffer BD, Fullerton C, Fleming N, et al. Arch Intern Med. 2011;171:1238-1243.

This study found that adoption of a nurse-led transitional care program produced a 48% reduction in readmission rates for elderly patients with heart failure. Interestingly, the outcomes achieved generated only marginal cost savings, suggesting the need for payment reform to better align incentives.
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