Transitional care models for high-need, high-cost adults in the United States: A scoping review and gap analysis.

This scoping review explored research literature on the integration and coordination of services for high-need, high-cost (HNHC) patients in an attempt to answer the following questions: What models of transitional care are utilized to manage HNHC patients in the United States? and How effective are they in reducing low-value utilization and in improving continuity?