Transitions of Care
Transitions of care are the movements of patients between settings (hospital, home, SNF, rehab, home health, hospice). Poor transitions cause readmissions, medication errors, and gaps. Know the transitional care elements: early risk assessment, medication reconciliation, discharge planning that begins at admission, patient/caregiver education, timely follow-up, handoff communication, and post-discharge follow-up calls or visits.
Understand medication reconciliation (compare pre-admission, inpatient, and discharge lists; resolve discrepancies; verify high-risk drugs - anticoagulants, insulin, opioids). Know handoff tools (SBAR, I-PASS) and the value of a transition coach or care transitions intervention. Recognize readmission risk factors: polypharmacy, low health literacy, social isolation, no primary care, multiple chronic conditions, prior admissions, and lack of transportation.
Traps: treating discharge as the end of care rather than a handoff; assuming the patient understands the discharge plan without teach-back; scheduling follow-up so late that it fails to catch early problems (aim for timely follow-up, often within days for high-risk patients); and failing to send the discharge summary to the next provider. Another trap is confusing transitional care (time-limited, bridging) with chronic care management (ongoing).
Rule of thumb: For high-risk patients, the transition is not complete until the next provider has the information, the patient can state the plan, and follow-up is scheduled and confirmed.
Worked example: A patient with COPD is discharged. The CM reconciles medications, uses teach-back for inhalers, sends the summary to the PCP, schedules a follow-up within a week, and arranges a follow-up call. Each step addresses a known readmission driver.