What Are Care Transitions?

Care transitions refer to a medical patient moving from one healthcare provider or healthcare setting to another. Seniors with illnesses, for example, may visit a primary care physician and then be admitted to a hospital and receive treatment from a hospital physician and nursing staff. Or a patient may transition from a hospital to their home or to a nursing home and later back to the hospital. Each of these changes in either location, level of care or healthcare provider is considered a care transition.

As a loved one is dealing with a health situation, often clear communication and coordination among doctors, nurses, social workers and other healthcare providers is overlooked. When this occurs, problems can arise in the actual care of the patient and with health insurance and Medicare coverage.

On their healthcare.gov website, the U.S. Department of Health & Human Services notes that, “Nearly one in five Medicare patients discharged from the hospital is readmitted within 30 days. This translates to approximately 2.6 million seniors at a cost of over $26 billion every year. Readmission rates are also high for patients covered by Medicaid and private insurance.”

One of the goals of care transitions is to provide safe and beneficial care to patients and reduce healthcare costs related to hospital readmissions and unnecessary treatment. Healthcare providers, patients and their caregivers can work together to make care transitions as seamless as possible and ensure that key information is provided across care settings, including:

• Primary diagnoses and major health problems
• Care/treatment plan with patient’s goals and preferences
• Patient’s goals of care, advance directives and power of attorney
• Reconciled medication list
• Contact numbers for transferring clinician/institution and caregivers
• Follow-up with the patient and/or caregiver within 48 hours of discharge

What experiences can you share about care transitions when your aging loved ones were receiving care?