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What do we mean by “Care Transitions”?
The term “care transition” refers to the movement patients make between health care
practitioners and settings as their condition and care needs change during the course of
a chronic or acute illness. For example, in the course of an acute exacerbation of an
illness, a patient might receive care from a PCP or specialist in an outpatient setting,
then transition to a hospital physician and nursing team during an inpatient admission before
moving on to yet another care team at a skilled nursing facility. Finally, the patient might
return home, where he or she would receive care from a visiting nurse. Each of these shifts
from care providers and settings is defined as a care transition.
Definitions
A recent position statement from the American Geriatrics
Society defines transitional
care as follows:
For the purpose of this position statement, transitional care is defined
as a set of actions designed to ensure the coordination and continuity of health care as
patients transfer between different locations or different levels of care within the same
location. Representative locations include (but are not limited to) hospitals, sub-acute and
post-acute nursing facilities, the patient’s home, primary and specialty care offices, and
long-term care facilities. Transitional care is based on a comprehensive plan of care and
the availability of health care practitioners who are well-trained in chronic care and have
current information about the patient’s goals, preferences, and clinical status. It includes
logistical arrangements, education of the patient and family, and coordination among the health
professionals involved in the transition. Transitional care, which encompasses both the sending
and the receiving aspects of the transfer, is essential for persons with complex care needs.
Research on Care Transitions
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