Transition of Care


Patients with complicated health problems often see several health care providers, a number that increases if treatment in a hospital becomes necessary. The patient may be treated by a primary care physician, various specialists in their medical offices, a hospitalist physician, nursing team in the hospital, a different physician, and nursing team during a stay in a skilled nursing facility, and a visiting nurse in the home.


Care can become fragmented when these providers work independently of one another or, worse, at cross-purposes. Even when each health care provider delivers high quality care, the result can be substandard care if his or her efforts are not coordinated.


Coordinating care and transitioning patients through multiple care settings require planning and execution. A successful transitional care process contains the following four elements:


  • Transition Workflow
  • Engagement
  • Communication
  • Measurement


Transition Workflow

Payers and providers who actively coordinate care for patients must develop several sets of transitional care workflows built on care coordination best practices. The workflows should be specific so that it covers patients based on diagnosis, medical history, conditions, social and cultural status, geography and outcomes.



Effective patient engagement strategy creates tight relationships between hospitals, PCPs, specialists and patients and delivers accurate and timely information to patients. The idea of waiting for patients to access portals to be engaged is a failure.


Not all patients have access to computers and smart phones. Your patient engagement strategy should heavily rely on actively pushing and pulling information to and from patients through different means of communication.



One main challenge is to communicate securely with patients and at the same time accommodating older patients with less access to technology.  Elderly and

low-income patients are most venerable and often left behind when it comes to the use of technology in healthcare. Care Coordinators must deploy multifaceted technology solutions that connect with patients based on the best method of communication available to the patient. Care Coordination communication strategy must be built on patients’ convenience, not the other way around



Organizations must keep track of all transitional care activities. Care Coordination planning starts from the time patient enters the hospital. Organizations must have methods in place that actively logs all care coordination interactions and encounters with patients, caregivers, providers and facilities. At the same time, organizations must constantly improve care coordination performance by reviewing processes, goals, gaps and outcomes. This can occur only if accurate and actionable data is collected.