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In the Clinic |

Transitions of Care

Christopher S. Kim, MD, MBA; and Scott A. Flanders, MD
[+] Article and Author Information

Acknowledgment: The authors would like to thank Dr. Mark Williams, Professor of Medicine, Northwestern University, for comments on an earlier version of draft of this manuscript.


Ann Intern Med. 2013;158(5_Part_1):ITC3-1. doi:10.7326/0003-4819-158-5-201303050-01003
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"Transitions of care" refers to changes in the level, location, or providers of care as patients move within the health care system. One critical transition of care that has garnered great attention and is the focus of this review is the transition involving hospital discharge. Acute hospitalization represents a significant event in a patient's life, and health care providers in partnership with patients need to address myriad issues related to the hospitalization and subsequent posthospitalization care for a safe transition out of the hospital. The care of the hospitalized patient has evolved over time, such that patients are sicker; length of stay has decreased; medical technology and knowledge have advanced; and new models of hospital-based care have evolved, such as the advent of hospitalists as the principal hospital-based providers. All of these factors have contributed to the complexity of coordinating transitions of care. In addition, as patients are discharged from a setting in which providers are available to address most health needs or questions on a continuous basis, patients and family members have good reason to wonder what will happen next. Recent research has highlighted the gaps in quality of hospital discharge transitions that may contribute to postdischarge complications. To address this problem, several federal, state, and local initiatives have prompted health care organizations and communities to identify, measure, and improve their care transition processes.

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Figure 1.

Teach-back concept, to help patients improve adherence and reduce errors in self-management. From reference 26.

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Grahic Jump Location
Figure 2.

Key process steps in discharge planning and transitioning patients to primary care ("Discharge Transitions Bundle").

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