Safe Transitions

What are Care Transitions?

Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient’s home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.

The Care Transitions Program, as defined by The American Geriatrics Society.

Transitions in care include a patient moving from primary care to specialty physicians; within the hospital they would include moving from the emergency department to various departments, such as surgery or intensive care; or when patients are discharged from the hospital to home, an assisted living arrangement, or into a skilled nursing facility.

The National Transitions of Care Coalition (NTOCC)