Care Transitions FAQs

Q: What does the term “care transitions” mean?

A: “The term care transitions refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. For example, a patient might receive care from a General Practitioner (GP) or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse.  Each of these shifts from care providers and settings is defined as a care transition.

Q: Why are hospitals interested in care transitions programs?

A: Impending cuts to Medicare spending will likely motivate hospitals to seek solutions within for reducing readmission rate since those rates will start to impact the Medicare payments they receive.  

Q: Should all hospital readmissions be prevented?

A:  No, not all readmissions are preventable.  If the cause for the readmission is not tied to the original admission then a patient should not be prevented from returning to the hospital.  It may also be necessary to readmit a patient even if the cause is tied to the original cause for admission. The objective for reducing preventable readmission is to increase the patient’s well being while also reducing the hospital’s cost but one should not occur at the expense of the other.