The term “care transitions” for Right at Home 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, in the course of an acute illness, 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 or rehabilitation 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.

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