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Implications for practice and research
A relatively simple, low-cost care transition intervention can encourage low-income, predominantly African-American elders to better utilise primary care, posthospital discharge.
An adequately powered study is needed in order to enable stronger conclusions to be drawn, particularly regarding the model's impact on hospital re-admission and emergency department (ED) visits.
Studies benefiting from high levels of minority participation should exploit this intervention through study design.
Improving management of care transitions is an important goal in health systems change, and various attempts have …
Competing interests None.