Care Coordination and Transitions of Care
Core concepts
Transitions of care-hospital to home, home to nursing facility, facility to hospital-are high-risk points for medication errors, information loss, and readmission. Key concepts: medication reconciliation at every transition, timely discharge summaries, follow-up appointments, and clear communication among the interprofessional team. Understand care coordination roles (case managers, care navigators, primary care) and the value of a transitional care model (e.g., follow-up calls, home visits). Recognize readmission risk factors: polypharmacy, functional decline, inadequate social support, and poor health literacy. Address social determinants and caregiver capacity. Use teach-back to confirm understanding.
Traps
Questions reward closing the loop-confirming the patient understands and has follow-up-rather than simply handing over a discharge paper. A common trap is failing to reconcile medications across settings or assuming the patient can manage alone. Another is discharging without arranging follow-up or caregiver support.
Rule of thumb
At every transition, reconcile medications, confirm understanding (teach-back), and arrange follow-up-the "handoff triad."
Worked example
An older adult is discharged on three new medications after a hospitalization. The best action is to perform medication reconciliation, use teach-back to confirm understanding, and schedule timely follow-up-not merely to provide a written list.