tients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, subacute and postacute nursing facilities, the patient’s home, primary and specialty care offices, assisted living, and long-term care facilities. Ideally, 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 should include logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition (Coleman and Boult, 2003).
Transitional care is distinguished from discharge planning in that the former encompasses both the sending and the receiving aspects of the transfer. Transitional care is primarily concerned with the relatively brief time interval that begins with preparing a patient to leave one setting and be received in the next. Many transitions are unplanned, result from unanticipated medical problems, occur in “real time” during nights and on weekends, and happen so quickly that formal and informal support mechanisms cannot respond in a timely manner.
While the focus of this background paper is on the “hand-offs” of care that occur as patients with complex care needs move across settings, it is important to acknowledge that transitional care shares key attributes with both coordination of care and continuity of care (Institute of Medicine, 2001, 2004). A comprehensive discussion of the latter two care domains is beyond the scope of this report. However, the intersection between transitional care, coordination of care, and continuity of care will be highlighted in this report.
Transitional care highlights a fundamental disconnect within the U.S. health care delivery system. The focus of transitional care is inherently patient-centered, attempting to ensure that the health care needs of patients with complex care are met irrespective of where care is delivered. But our health care delivery system, whether examined by payment, quality improvement initiatives, accreditation, performance measurement, or how clinicians define their practice, is increasingly setting-centered. In many respects, the term “health care system” is a misnomer. There are few mechanisms in place for coordinating care across settings, and often no single practitioner or team assumes responsibility during patients’ transitions. As was discussed during the December 1st 2004 Workshop, Dr. Mark Miller, Executive Director of MedPAC, acknowledged that organizing payment and quality setting by setting is not satisfactory. He expressed, however, that there exists a high level of interest in better coordination of these activities across settings.