The Challenges of Care Transitions and Best Practices Resources

April 1, 2021
April 1, 2021

This blog post is the next installment in an ongoing series relating to our Living Labs Program by Richard Galentino, Ed.D., Vice President, Professional Development Pathways & Living Labs, HealthStream.

Let’s face it, transitions in life are challenging. These challenges can be especially difficult for vulnerable populations like the elderly, and particularly the frail elderly. Nearly one in five Medicare patients—approximately 2.6 million seniors—are readmitted within 30 days1. Many of these readmissions are avoidable and the percentage of hospitals receiving a penalty increased to 78% in FY20152. Reasons for high readmissions include, but are not limited to the following factors:

  1. Unclear discharge processes
  2. Quality of care in the next setting
  3. Coordination of care
  4. Lack of resources
  5. Patient’s ability to manage self-care
  6. Low health literacy

A number of research studies have illustrated processes and activities that hospitals can undertake to lower readmissions, including better discharge processes and better coordination of care with post-acute facilities and primary care doctors3.

Over the past year, we have worked with the Duke School of Nursing and Duke School of Medicine to develop a certificate program (The Duke Interprofessional Frail Elder Certificate Program) that will improve the quality of care for frail elders—part of the population that often suffers from needless readmission. Care transitions is one aspect of the program.

In order to improve care transitions, a conscious effort must be made by the whole interprofessional care team. When we get busy it’s easy to focus on our role as a PT, RN, or MD without considering the suggestions or input from the whole interprofessional team. As you review your care transition program, especially as it relates to vulnerable populations like frail elders, here are seven intervention categories noted by the National Transitions of Care Coalition4.

Patient and Family Focused Interventions

  1. Medication management
  2. Transitional care planning
  3. Patient and family engagement and education

Provider focused interventions

  1. Information transfer
  2. Follow-up care
  3. Healthcare provider engagement, and
  4. Shared accountability across organizations

Here is a great resource for taking a deeper dive into these seven intervention categories by the National Transtions of Care Coalition.

When thinking about care transitions, it’s important to remember family and friends as they can be critical to a successful care transition. Here is a good guide for patients and their families to organize their care.

I find this particularly useful as it focuses on medication management a key part of a successful transition.

Learn more best practices with respect to Care Transitions and the Continuum of Care at an upcoming Webinar on November 6 with the faculty leadership team who created the Duke Interprofessional Frail Elder Care Certificate Program. Information will soon be posted here.


  3. Ahmad, Faraz S. et al., “Identifying Hospital Organizational Strategies to Reduce Readmissions,” American Journal of Medical Quality Vol. 28, No. 4: 278-285, 2013.; and Silow-Carroll, Sharon et al., “Reducing Hospital Readmissions: Lessons from TopPerforming Hospitals,” Commonwealth Fund Synthesis Report, New York: Commonwealth Fund, 2011.; and Jack, B. W. et al., “A Reengineered Hospital Discharge Program to Decrease Hospitalization: A Randomized Trial,” Annals of Internal Medicine Vol. 50, No. 3: 178-187, 2009.; and Kanaan Susan B., “Homeward Bound: Nine Patient-Centered Programs Cut Readmissions,” Oakland, CA: California HealthCare Foundation, 2009.
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