TY - CHAP M1 - Book, Section TI - Transitions and Continuity of Care A1 - Eng, Jessica A. A1 - Flint, Lynn A. A2 - Walter, Louise C. A2 - Chang, Anna A2 - Chen, Pei A2 - Harper, G. Michael A2 - Rivera, Josette A2 - Conant, Rebecca A2 - Lo, Daphne A2 - Yukawa, Michi PY - 2021 T2 - Current Diagnosis & Treatment Geriatrics, 3e AB - 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. SN - PB - McGraw-Hill Education CY - New York, NY Y2 - 2024/03/28 UR - accessmedicine.mhmedical.com/content.aspx?aid=1180015193 ER -