Before discussing the strategies to improve care transitions, let’s understand what care transitions are? It is referred to as the movement of patients between health care practitioners, settings, and home as their condition and care need change. Often, ineffective care transitions lead to adverse events, leading to higher hospital readmission rates and costs. To reduce both the readmission rates and adverse events, hospitals must improve the effectiveness of care transitions. Here we will discuss some effective strategies for the same bur before going to the strategy, let’s take a look at why do we need strong care transitions:

Studies have shown that almost 43% of patients leaving the hospital need to enter some post-acute care, increasing the spending. A survey by the Institute of Medicine found variation in post-acute care spending accounts for 73% of the variation in total Medicare spending. This unbridled utilization will place an increasing demand on the care transition, which is already burdened with extreme variance and unsustainably high costs. The lack of technology makes it even more difficult.
To address all these issues and improve care transitions, it is crucial to bring in significant strategies. Let’s discuss the strategy which can be implemented to improve care transitions.

  1. Focus on caring rather than a business: Many studies have shown that hospitals often keep patients for a more extended period than medically necessary, recognizing the financial benefits connected with a prolonged stay. Rather than focusing on the money bit, hospitals should focus on the care part. Here is a big opportunity for all the hospitals to improve.
  2. Understand the functional status: Clinicians and hospital staff must fully assess the condition of the patient from the hospital to post-acute care. Understanding a patient’s individual functional status allows the staff to predict where a patient needs to go for post-acute care, the length of the stay, therapy requirements, and estimated discharge date. This strategy should be implemented to improve care transitions.
  3. Improve Communication: There have been many cases where the patient was suggested to have a particular diet despite suffering from an illness that demanded a specific diet. To fix this disconnect, communication should be improved. The primary care providers should meet one-on-one with a team member from the post-acute care facility to discuss the care transition process and review all care orders for the patient. Immediately make corrections, and adjustments should be made to improve care transitions.
  4. Proactive Discharge Planning: Generally, in the care transition process, discharge planning starts two days prior, a patient leaves the care facility. A discharge plan is made through care transition services as soon as the patient is admitted to the post-acute facility. The proactive discharge planning enables identifying the exact number of days the patient should stay at the facility to achieve the functional goals.
    Proactive discharge planning also supports patients’ transition from the skilled nursing facility to their homes by highlighting any non-clinical needs patients might have, for example, bathing or feeding, which gives families plenty of time to figure out how to meet those needs.


There are several potentially useful strategies to improve care transitions. However, a proper process is required to execute them. There are three main research priorities which, according to us, should be worked upon on priority:

  • Development and testing of interventions to facilitate person and family-centered care starting at the time of admission
  • Development of resources to manage sub-acute health conditions
  • The delivery of transitional care to support residents and families when nursing home care completes.

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