“…Care transition models have been implemented across the United States to reduce hospital readmissions and other adverse events in high-risk populations, such as adults older than 65 years with multiple comorbidities (Baldwin et al, 2018; Schletzbaum et al, 2023). Several care transition models focus on nurse-led care transition interventions with varying success (Ballard et al, 2018; Berkowitz et al, 2018; Finlayson et al, 2018; Gilbert et al, 2021; Hall et al, 2020; Jack et al, 2009; Joo & Liu, 2021; Kripalani et al, 2019; Morkisch et al, 2020; Schnipper et al, 2021; Vergara et al, 2021; Yiadom et al, 2020). Care transition models, such as Better Outcomes for Older Adults Through Safe Transitions (BOOST), Care Transitions Intervention Model (CTI), the Transitional Care Model (TCM), Project Red, and the Johns Hopkins Community Health Partnership (J-CHiP), have positive outcomes of reduced hospital readmissions, improved communication among care team members, reduced health care costs, and improved patient experiences (Ballard et al, 2018; Berkowitz et al, 2018; Hall et al, 2020; Jack et al, 2009; Joo & Liu, 2021; Kripalani et al, 2019).…”