BACKGROUND Patients with complex health conditions frequently require care from multiple providers and are particularly vulnerable to poorly executed transitions from one healthcare setting to another. Poorly executed care transitions can result in negative patient outcomes (e.g. medication errors, delays in treatment) and increased healthcare spending due to re-hospitalization or emergency roo...

Refugees tend to have greater vulnerability compared to the general population reporting greater need for physical, emotional, or dental problems compared to the general population. Despite the importance of creating strong primary care supports for these patients, it has been demonstrated that there is a significant gap in accessing primary care providers who are willi...

INTRODUCTION Miscommunication and lack of coordination can compromise care quality and patient safety during transitions in care, especially for medically complex older adults. Little research has been done to investigate care transitions from the perspective of those receiving and providing care. METHODS This study explored multiple care transitions for an elderly hip fracture patient, post-...

OBJECTIVES The purpose of the study was to examine the frequency of burdensome care transitions at the end of life, the difference between different types of residential care facilities, and the changes occurring between 2002 and 2008. DESIGN A nationwide, register-based retrospective study. SETTING Residential care facilities offering long-term care, including traditional nursing homes, sh...

Community Care of North Carolina initiated efforts to improve care transitions for North Carolina Medicaid recipients in 2008. The transitions program is now statewide, serving more than 4,000 patients every month, virtually every North Carolina hospital, and more than 1,400 primary care practices. This commentary describes program components, early outcomes, and future challenges.

Multiple transitions between care settings in the last phase of life could jeopardize continuity of care and overall end-of-life patient care. Using a mortality follow-back study, we examined the nature and prevalence of transitions between Dutch care settings in the last 3 months of life, and identified potential characteristics associated with them. During the 2-year study period, 690 registe...

BACKGROUND Effective and efficient transitions in care between emergency medical services (EMS) practitioners and emergency department (ED) nurses is vital as poor clinical transitions in care may place patients at increased risk for adverse events such as delay in treatment for time sensitive conditions (e.g., myocardial infarction) or worsening of status (e.g., sepsis). Such transitions in ca...

Objectives: Objectives were to (a) describe transitions between care settings in older homecare recipients at the end of life, and (b) examine what personal (e.g., age, sex) and health system factors (e.g., hospital bed supply) predict care transitions. Methods: The study involved analysis of administrative health care data and was based on a complete cohort of homecare recipients aged 65 years...

Background: Poorly coordinated care between hospital and outpatient settings, and delayed access to primary care contributes to hospital readmissions. Given financial penalties for readmissions, hospitals are investing in interventions to improve care transitions following discharge. In parallel, Medicaid managed care organizations are providing incentives to primary care clinics to improve car...

Older persons suffer from complex and chronic health conditions that require ongoing self-care activities as well as management by health care professionals. Older adults commonly receive care in multiple settings (hospital, skilled nursing facility, ambulatory clinic, home) necessitating transitions between settings of care. Multiple strategies have been proposed to aid care coordination betwe...