Transitional Care is the care provided to a patient as they transition from one care setting to another. In this case we are talking about the transfer from a Hospital or Skilled Nursing Facility that is discharging a patient back to their home. These Care Transitions are a critical health and social problem for seniors and their in-home caregivers.

Why is Transitional Care Important?

If you have been a patient in a facility you know that the discharge is the moment we hope and pray for each day. Going home means familiar smells and surroundings and we consider it comfortable and safe; unfortunately, that is not always the case.

As a hospital patient you often don’t sleep well, you may be on new medications, your body may have been through multiple traumas and your stress level is probably at an all-time high. Into the room walks the discharge planner with your discharge instructions and papers for the patient to sign.

Patients are at risk during the transition of care for medication errors, service duplications, and inappropriate care. Important things like care plans can fall through the cracks and communication between care providers can be non-existent.

Benefits of Transitional Care

Chronic diseases make up a large part to hospital readmissions, but in reviewing patients who had been readmitted to a facility within 30 days of discharge, there are other prevalent issues at play as well:

  • Medication errors or non-adherence
  • Lack of follow-up with the Primary Care Provider (PCP)
  • Complications related to discharge diagnosis
  • Non-adherence with a care plan or the discharge plan

The answer to reducing readmissions and delivering patient-centered care is an integrated disease management program in which:

  • All involved physicians collaborate
  • Special emphasis is placed on patient education and empowerment
  • A homecare provider specializing in transitional care is engaged
Physician Collaboration

When it comes to optimizing patient outcomes, it is imperative for all involved physicians to come together to apply their complementary skills, knowledge and competencies. This involves a mutually agreed upon division of roles and responsibilities as well as an “all hands on deck” mentality.

Patient Education

A key piece of the care equation is the patients themself. A solid disease management program will account for this by providing educational materials and resources to empower the patient and their family to better manage his/her chronic illness.


Patients and physicians alike should look to an in-home care provider with an evidence-based, condition-specific transitional care program that is coordinated by an RN to provide people with chronic illness with the education and supervision they need to reduce the chance they’ll be readmitted to the hospital.

Together, these elements create a patient-centered trifecta that is effective in reducing hospital readmissions and improving patient outcomes.