Transitions in care that are based on patient needs involve logistical arrangements to move a person from one care setting to another or from one care provider to another. To ensure continuity of care, transitions in care should be coordinated among knowledgeable and skilled health care professionals who are familiar with the person’s clinical status, goals of care, plan of treatment, care plan, and health information needs.
Timely and effective communication is essential to prevent problems that may occur if services and supports are not well integrated (e.g., delayed transfers, readmissions, or poor care). Identifying a member of the care team to be accountable for care coordination supports a smooth transition between settings and prevents communication failures. Information-sharing between settings to ensure all health care providers are aware of the person’s current condition is part of effective and coordinated communication. All information-sharing during care transitions must consider legislated privacy and security requirements.
Families and caregivers also play a vital role in transitions. Health care professionals should have informed discussions with them about available care settings. Health care professionals should work together, and with the patient, their family and their caregivers, to ensure that transitions in care are timely, appropriate, and safe.