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The term care transition refers to the transfer of a patient’s care from one setting and/or team of clinicians to another. The most-studied care transition is hospital discharge, which is often more complex than a simple return home. What follows is an example of a typical series of transitions after hospitalization: An older adult with a chronic condition, followed as an outpatient by his primary care physician and a specialist, is hospitalized for exacerbation of the chronic condition, where a hospital-based generalist and specialist physicians, nurses, and therapists care for the patient. The hospitalization is this patient’s first transition. During the hospitalization, the patient may move between units within the hospital due to changing care needs, a second transition. When the patient no longer requires acute-level care, the patient may receive postacute care (PAC) from a new team, such as rehabilitation or skilled nursing care, in a facility or at home, a third transition. When the patient is discharged from the facility or home health team, a fourth transition occurs. With so many handoffs, mishaps are inevitable. Transitional care broadly refers to time-limited care processes aimed at avoiding such mishaps and ensuring safe and minimally disruptive transfers of care between different sites and clinicians.


Care transitions drew increasing attention in the late 20th century for a variety of reasons, including changes to the financing and structure of the US health care system and a shift in the types of illnesses prompting hospitalization, from acute episodic illnesses to exacerbations of chronic illnesses and multimorbidity. Prior to 1983, in the single disease–focused fee-for-service payment scheme, Medicare beneficiaries stayed in the hospital for longer periods of time, until near complete recovery. In 1983, to address rapidly increasing health care costs, Medicare was changed from fee-for-service payment to prospective payment. Prospective payment meant that hospitals received predetermined diagnosis-based fees for entire hospitalizations and created a financial incentive for hospitals to increase efficiency and shorten length of stay. Indeed, length of stay decreased with the reform, but patients were not only discharged “quicker,” they were also discharged “sicker.” Facility-based PAC use increased, as did hospital readmission rates. In one retrospective study of all Medicare beneficiaries, 22% experienced at least one care transition over the course of a year. Concurrently, fast-paced advances in hospital medicine coupled with the push to improve efficiency prompted physicians to restrict their practice to single sites (ie, clinic or hospital). Fewer primary care physicians continued to follow their patients while hospitalized. This shift in practice patterns meant that patients’ care would routinely transfer care from one care team to another when moving between settings.

Finances may also subtly encourage frequent transitions between nursing home and hospital for long-term nursing home residents. Medicare-certified skilled nursing facilities (SNFs) often provide temporary skilled rehabilitation and nursing services to their residents returning from the hospital. Reimbursement for skilled services is higher than the rate ...

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