Why So Many Care Transitions Aren’t Smooth, and How to Improve Them

While being released from the hospital may come as a relief to many patients eager to go back home, the transition can be fraught with anxiety-inducing, expensive, and even dangerous challenges. One analysis of Medicare claims found that almost one fifth of beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and over a third were rehospitalized within 90 days.[1] What is causing those patients to return, and why with such prevalence? This post aims to answer these questions and provide some best practices that can reduce the rates at which patients find themselves experiencing insufficient care transitions.


What is so difficult about care transitions?

The movement of a patient between health care settings and their home is difficult because the patient goes from having around the clock supervision and care by professionals to being cared for by friends, family, or just themselves, none of whom will likely have the knowledge and experience of a hospital medical staff. Individuals may find themselves readmitted to a hospital for a variety of diagnostic and therapeutic errors, but the most common and harmful are adverse drug events due to confusion or errors relating to medication.[2] Additionally, relapses in conditions, complications from procedures, infections, and falls are all reasons that can land an individual back in a hospital after leaving not long before.[3]


Why do ineffective transitions of care occur?

A complex set of factors contribute to poor transition of care and readmission to hospitals. One root cause is communication breakdown, in which care providers do not effectively or completely communicate with each other, with their patients, or to a patient’s caregiver, be it through written or verbal instruction.[4] This can be due to differing expectations, cultural or language differences, inadequate time for a successful handoff, or patient conditions a physician is unaware of, and lead to gaps in care coordination or inadequate instructions at discharge.[5] However, factors like poor social support, poverty, health literacy, and access to quality, outpatient care are outside of a hospital’s control, and are just as dangerous to patients trying to transition out of a hospital setting.[6]


How can care transition be improved?

Based on some of the above problems, here are some best practices that can potentially change the way in which care transitions are currently being conducted:

  • Multidisciplinary communication. As we’ve pointed out in numerous blog posts, communication, collaboration, and coordination between care team members is critical for the wellbeing of a patient.[7] It can decrease the chance that a patient will get mixed or incomplete information, and that an error or concern will be overlooked.
  • Completing comprehensive risk assessments throughout hospital stays. The discharge risk assessment sent home with every patient should be added to throughout a patient’s entire stay, and address not only concerns at the hospital, but where the patients might be lacking in access or support at home.[8]
  • Standardization. Standardizing medical staff training, transition plans, procedures, and forms can ensure that all members at a hospital know what is expected when it comes to care transitions, and risks they should be on the lookout for.[9]
  • Complete medication reconciliation. At a transition, clinicians need to check the accuracy of medication types and dosages and look for contradictions to reduce the chance of medication error.[10] Additionally, they should assess financial barriers that might keep patients from following through with prescriptions.[11]
  • Employ the “teach back” method.” This technique encourages doctors to ask patients to restate instructions or concepts in their own words, demonstrating that they are confident in their understanding of their condition and needs once leaving the hospital.[12]
  • Ensure support and follow-ups. Before a patient leaves, hospital staff should schedule follow-up appointments and help coordinate follow-up care for patients who need assistance.[13]


With so many factors involved, some out of a hospital’s control, it is clear that there is no possible way to make every care transition a good one. However, with a well-trained, reliable staff with standardized and thought-out methods, there is definitely hope that more care transitions can increase a patient’s chance of healing.


As legal nurses we provide chart review and analysis for our attorney clients and their potential medical negligence cases. We look at the whole health care system- from acute care hospital stays and transitioning nursing home or assisted living facilities and/ or primary care providers. In addition, we focus on the potential problems in the discharge planning and the patient’s ability or inability to follow medical advice. Let us know if you need help reviewing your client’s medical chart notes; we can uncover the potential red flags and areas of negligence saving you and your practice valuable time.

[1] Jencks, S. F., Williams, M. V., & E. A. Coleman, “Rehospitalizations among patients in the Medicare fee-for-service program”, NCBI, Apr 21, 2011, https://www.ncbi.nlm.nih.gov/pubmed/19339721

[2] Rennke, Stephanie, & Rumant R. Ranji, “Transitional Care Strategies From Hospital to Home,” The Neurohospitalist, July 10, 2014, http://journals.sagepub.com/doi/abs/10.1177/1941874414540683?journalCode=nhoa

[3] Dreyer, Theresa, “Care Transitions: Best Practices and Evidence-based Programs,” Center for Healthcare Research & Transformation, Jan. 15, 2014, http://www.chrt.org/publication/care-transitions-best-practices-evidence-based-programs/

[4] “Transitions of Care: The need for a more effective approach to continuing patient care,” The Joint Commission, June 2012, https://www.jointcommission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf

[5] Ibid; Rennke & Ranji, “Transitional Care Strategies”

[6] Rennke & Ranji, “Transitional Care Strategies”

[7] “Transitions of Care”

[8] Ibid

[9] Ibid

[10] Dreyer, “Care Transitions: Best Practices”

[11] Ibid

[12] Ibid

[13] Ibid