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Transition of Care Lesson

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Author: Himabindu Lanka, MD

Academic Hospitalist, Cooper University Hospital



Comprehensive planning and execution of moving patients from the one health care setting to another or home based on their level of care.


Importance of Extensive focus on Transition of Care

  • Current Readmission rate is 20% within 30 days
    • Communication Breakdowns: between patient and provider and hospital provider and PCP
    • Patient Education Breakdowns
      •  Health literacy plays a role
      •  Receiving conflicting information: which leads to patients not knowing what to do upon transitioning

Who should be involved in transition of care planning?

Interdisciplinary approach with patient centered care:

  • Social services
  • Nurses
  • Patients and patients’ families
  • Provider (MD, NP, PA) in the hospital
  • Primary Care physician as applicable


Information to be included at discharge when patient is being transitioned from hospital to community, rehab facility or LTACH

  • Reason for hospitalization
  • Tests and treatments provided during hospital stay
  • Instructions for what to do upon discharge
  • Medications
    • New: started during the hospitalization and will be continued. Reason why it was started and duration
    • Continued home medications: note to explain if any dose changes or frequencies were changed
    • Discontinued and reason for discontinuing
  • Signs and symptoms to monitor for and what to do when they occur: call PCP or go to ED
  • Follow up instructions with PCP and specialists as needed
  • Follow up testing as needed: communicate with PCP as appropriate


Models for Transition of Care

Better Outcomes by Optimizing Safe Transitions (BOOST): mentored implementation made by Society of Hospital Medicine


Important Pearls

  • Exercise teach back with patients especially when new information is being given to them and keep it simple
  • Involve families and caregivers in the discharge process especially in a complex patient with multiple co-morbidities



Kim, Christopher, MD, MBA, Flanders, Scott, MD. In the Clinic: Transitions of Care. Annals of Internal Medicine, 2013: ITC 3-1 to 3—14

Transitions of Care: The need for a more effective approach to continuing patient care. Joint Commission. 2012