Care transitions, when patients move from one setting to another, such as from hospital to nursing home or from hospital to home, are perilous times. Poorly executed transitions can lead to increased suffering for patients and families and higher costs. Improving transitions regularly improves health outcomes, reduces costs, and helps patients to understand their health conditions and how to manage or monitor them. Many clinicians and other stakeholders nationwide are working to understand and demonstrate how best to improve transitions. Many are also sharing their stories, learning from one another about effective strategies and techniques.

Although shortcomings in care transitions harm individuals, these shortcomings also reflect larger, systemic problems that can best be resolved by many stakeholders working together. Indeed, no single individual or organization will be able to optimize care transitions. It will truly “take a village” to make transitions safe, effective, and routine. Building community coalitions focused on improving care transitions is one effective way to engage diverse stakeholders in achieving common goals around transitions. Many provider organizations and civic leaders around the country are doing just that.

This guide offers ideas and pointers for how to get started and keep the momentum going. Here, you’ll find leads on improvements that work, along with how to use measurement to advance goals, how to find good data sources, and how to decide what to measure. The guide provides very specific information and links to help you find what works to fix care transitions, including how to fix the hospital discharge process and how to target rehospitalization. It provides an overview of coalition building, ranging from recruiting partners to resolving governance. It describes what to consider when setting priorities for the work. Because care transitions have a major effect on very sick patients and their families, this guide also includes ideas for how coalitions can optimize use of palliative care programs and services.

This guide offers a starting point. We hope you find it compelling and useful. As you realize that you can use more detailed information, please use our Care Transitions Search Widget, which is customized to yield the best of the Internet for your queries. When you need even more, let us know at eldercare@altarum.org and we will do all that we can to help.

Download Care Transitions Guide (.pdf, .prc or .epub formats)