Transitional care encompasses a broad range of services and environments designed to promote the safe and timely movement of patients between levels of health care and across care settings. High-quality transitional care is especially important for older adults with multiple chronic conditions and complex care needs. Any gaps in care that exist for patients and their caregivers during critical transitions can lead to adverse events, unmet needs, low satisfaction with care, and high hospital readmission rates. Improving the quality of care for chronically ill older adults during critical transitions is important for lowered healthcare costs and improved health outcomes.
Nearly 13 percent of Medicare beneficiaries discharged from hospitals experience three or more provider transfers during a thirty-day period. Approximately 20 percent of Medicare beneficiaries discharged from hospitals were readmitted to a hospital within thirty days and more than 30 percent are readmitted within ninety days. It is during these transitions that mistakes commonly occur giving rise to adverse clinical events. For example, a patient transitioning from a hospital to a nursing home or other facility may not have their medication and treatment plan communicated clearly. There may be discrepancies in the prescriptions, medical supplies or care instructions for home health as another example.