blog post 9.13.13

Possible Solutions to Transition of Care Issues and Problems

This blog post excerpts an article by Randy Carden, Ed.D; Senior Research Consultant,

HealthStream, in the Q3 2015 issue of PX Advisor, our quarterly magazine designed to bring you thought leadership and best practices for improving the patient experience.


Why Are There Issues with Transitions of Care? Where Are We Vulnerable?

What makes care transition points so difficult? Why are the “hand-offs” prone to issues? Several points of vulnerability are listed below.

Challenges with the Elderly

The elderly experience more difficult transitions than younger patients due to multiple health issues, possible cognitive slippage, dependency, and multiple medications. It is estimated that almost two-thirds of readmissions from nursing homes could be avoided.

Brief Medical Encounters

Our current model tends to be typified by brief medical encounters where we focus on treating disease states rather than the person.


Patient education and specifically poor health and healthcare literacy are related to transition issues and increased probability of readmission.

Failures in follow-up, support and coordination of care

Patients often have issues with remembering post-discharge instructions and following discharge plans. This can have profound implications, because most of the time the patient bears much of the responsibility for his or her care.

Medication Errors

Medication errors were found to be present in about half of all discharged patients. These errors were more common in patients with poor health literacy and lower numeracy or the ability to use and understand numbers.

Fragmentation of Care

Historically, hospitals and post-acute providers have not been well-connected. There has been a failure to account for challenges that may occur once patients are sent back into the community.

Social Challenges

Lack of social support can be a major problem. Basic things like transportation, food preparation, following dietary restrictions, and taking medications properly often prove to be overwhelming.

Possible Solutions to Transition of Care Issues and Problems

What is to be done to help remedy the situation? The following culture change ideas have been suggested as ways to improve the transition from hospital to other providers or the community.

Enhanced Communication

One of the most effective interventions would be more effective communication. A recent study by Record et al. (2015) supports the proposal for improved communication. They found that a post-discharge physician-initiated telephone call was related to higher scores on the 3-item Care Transitions Measure (CTM- 3), which assesses patient perception related to readiness for the transition from hospital to home. Higher scores predict reduced likelihood of a visit to the emergency department within 30 days of discharge.

Patient as Consumer

A recommended culture change is the change in orientation from patient to consumer. Recent positions by the Joint Commission and CMS may help reinforce this change in our thinking. The Joint Commission is advocating for better collaboration and coordination around transitions to reduce readmissions. Furthermore, the relatively recent advent of the CAHPS surveys is playing an important role in establishing the patient as consumer. CAHPS surveys allow patients as consumers to evaluate care based on standardized items that are comparable nationally. These new initiatives associate reimbursement with outcomes and are receiving profound attention.

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