Name and describe at least two risk factors that can increase hospital readmissions

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Question description
Now that we know about residential and home and community-based long term care services in the US, we need to look at how consumers transition from one type of care setting to another, including transitions from the hospital to these settings. These transitions have become increasingly important with greater emphasis on reducing hospital readmissions and increasing patient and resident safety under the ACA.
1.  What types of consumers require complex care management as they move through the various dimensions of long-term care services?  Name and describe at least two risk factors that can increase hospital readmissions for these individuals.
2.  What is a transition plan, and why is this important for health care providers to put into place for consumers recently discharged from an acute care setting?  How can an ecomap help to create a transition plan for a consumer back to the community?
3.  How can greater attention to a consumer’s level of pain or a consumer’s probability of having a dementia diagnosis help care transitions?  Can contact with a consumer’s caregivers (if they have them) improve the care transition process.
Just one paragraph for each questions, with no more than three sources in APA format. Please, cite the sources in APA format.
Please, make sure you provide a complete answer, with no grammar issues and plagiarism. 
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