What is Transitions Care?

Transitions Care, also known as Care Transitions, can be defined as care provided to the patient who is transitioning from one healthcare setting (such as a hospital or skilled nursing facility) to another setting (such as patient’s home or long-term care facility).


Why is Transitions Care Important?

Patient transitions are extremely critical periods where patients with complex medical needs, primarily seniors, are vulnerable to poorer health outcomes. Proper coordination and continuity of care during the transition periods is vital for preventing adverse patient outcomes.

Lack of proper transitions care is one of the major causes for hospital readmissions or re-hospitalization, especially within thirty days after discharge. According to the Centers for Medicare & Medicaid Services, the current hospital readmissions rate within thirty days of discharge is 18%. This means about one in six patients are readmitted to the hospital within thirty days of leaving the hospital. While the number is startling, the encouraging part is that over three quarters of such readmissions are preventable.


What are the issues afflicting Transitions Care currently?

Transitions Care got attention through the establishment of the Hospitals Readmissions Reduction Program (HRRP) in 2012, part of the Affordable Care Act. Since then, the healthcare community has been focusing on streamlining transitions care which has helped with the downward trajectory of the readmission rates.


However, till the full adoption of proper transitions care procedures, issues that affect transitions care include:

Poor communication between healthcare providers and inconsistent sharing of vital patient information.

Lack of adherence to medication plan due to ill-understood instructions, drug-drug interactions, prescription fulfillment.

Confusion among patient, patient’s family and family caregivers, post-discharge, about roles and responsibilities involving caregiving to the patient.

Inconsistent follow-up visits with required healthcare providers.

Lack of knowledge about available alternatives such as home care providers to help implement a well-structured Transitions Care Plan.