Tips on Creating a Smooth Patient Care Transition

By Karen Anne Wolf on Tue, Dec 11, 2012

patient care transitions, health care systemThe hectic pace of nursing can make doing discharges seem to be a bothersome chore for nursing staff. While many hospitals and long-term care settings may have a case manager or care coordinator, this does not relieve the nurses, as patient advocates, from their responsibility to work with the health care team to make sure that there is accurate information, along with the necessary resources, to support patient care transitions.

Let's consider this situation as an example.

Mrs. Lake, recently diagnosed with a serious heart problem, cardio-myopathy, was readmitted to the hospital with an unrelated GI illness.  Upon discharge to a rehabilitation center, the discharging staff failed to relay her cardiac diagnosis, medication, diet and activity. This failure to communicate led to an episode of congestive heart failure, increased stress for the patient, and a longer course of recovery.

In this particular scenario, where did the breakdown occur? Being a patient is a stressful experience. Patients face multiple transitions, or “hand-offs,” in settings and caregivers. Mrs. Lake went through at least three major transitions from the emergency departments, to the intensive care unit, and then on to the inpatient units before being sent to a long term/rehab setting and finally home.


This system breakdown lengthened Mrs. Lake’s rehabilitation course and complicated her course of recovery.  Similar to many patients who are causalities of our health care system cracks, Mrs. Lake was made even more vulnerable by multiple chronic diseases.  The costs of such breakdown include slow recovery, and more often than not, add to the cost of health care, by adding to unplanned re-hospitalization.  A recent study of Medicare estimates that the cost of unplanned rehospitalizations in 2004 was $17.4 billion.1 

patient care transitions, health care system

Communication and coordination can and should prevent such omissions at the time of transition.2 This includes the following key components: 

  • Take time to educate the patient and their family members about the plan of care. If discharging the patient, provide a thorough, accurate plan.  Always assess the patient and family’s understanding of the plan.  Don’t forget the basics of nursing care, such as skin care, bowel and bladder care, and medication administration. 
  • Make sure that there is an accurate listing of diagnosis and any procedures that were done.
  • Always reconcile the patient’s medications when “transitioning” the patient.  In addition, verify medication by name to match generic and/or brand names.  This may mean faxing or phoning the medication list, and reviewing the list with the health care team members and family.
  • Be sure that other key aspects of the plan of care post transition are included for the next transition site: diet, exercise, treatments, therapies as well as equipment should be outlined in addition to medications.  
  • Be sure there is clarity about when, where and with whom follow-up care is scheduled. This includes who should be called if the patient has a problem.

When it comes to discharge and coordination of patient care, the challenge for the future is to be proactive and creative to establish and expand systems of care that support our patients. In a recent Hastings Center Report, nurse Mary Naylor and colleagues suggest that health care providers need to work with patients, family and other caregivers if they want to be successful.  “Be realistic” and develop care plans that patients can live with, and “make sure that there is professional support and follow-up through the critical period following hospitalization”. 3


The health care systems of the future need topatient care transitions, health care system assume responsibility for the care of our patient - vulnerable or not.  Communication in nursing and coordination of care will most likely include the technologies of electronic medical records and home care reminder calls. However, the technologies of care will only be as good as the effective and accurate care coordination of the full patient - family centered health care team.



1. Jencks, SF., Williams, MV. Coleman, EA. (2009).

Rehospitalizations among Patients in the Medicare Fee-for-Service Program

New England Journal of Medicine, 360: 1418-1428


2.  Greenwald JL, Denham CR, Jack BW (2007). The Hospital Discharge: a review of high-risk care transition with highlights

of a reengineered discharge process. Journal of Patient Safety



3. Coleman, E, Levine, C and Naylor, M.  (2009). The Missing Link in Chronic Care Coordination Caregiving. The Hastings Center Report Vol. 39, No. Retrieved July 2, 2009 from


4. The Commonwealth Fund:


For further reading:


AARP (2009). Chronic Care: a Call to Action for Health Care Reform.  Retrieved July 3, 2009 from


Anthony D. Chetty VK, Kartha A, et al. Re-engineering the Hospital Discharge: An Example of a Multifaceted Process. In: Advances in patient safety: from research to implementation [online]. AHRQ 050021 (2). Agency forHealthcare Research and Quality. 2005 Feb [cited 2008Apr 16]. Available from Internet:

New Directions in Health Care: The Commonwealth Fund Podcast

About the author: Dr. Wolf is associate professor at Samuel Merritt University in Oakland California. She has practiced as a community health nurse and adult nurse practitioner; and has served as a nurse educator for more than 25 years. Formerly Associate Director of the Program in Nursing at the MGH Institute in Boston, Dr. Wolf also served as nurse practitioner and director of health & wellness for the Cambridge Health Alliance Senior Health Center. She has lectured and published widely on professional issues and nursing history, aging and health policy.

Click here for more information on Karen Anne Wolf.

Nurses, if you enjoy writing on nursing career, education or lifestyle related issues and are interested in becoming a contributor, please click here.

Did you like this article? Share it!

if you enjoyed this article.


Anonymous 1 year ago
I have been in a pilot program for transitions of care. It was designed to improve communication and improve the transition from the hospital to home. I believed strongly in the program. I was shocked to find it discontinued yesterday without notice. Apparently the hospital has decided to act not work on decreasing their high readmission rate. I find this very distressing for the patient and their families.