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Table of Contents

Magill’s Medical Guide, 9th Edition

Transitional care

by Muneeza Khan. MD, FAAFP

Category: Specialty

Also known as: Care transitions, transitions of care, transitional care management

Anatomy or system affected: All

Specialties and related fields: All

Definition: A set of actions designed to ensure the coordination and continuity of health care as patients transfer between locations or different levels of care in the same location.

Transitional care is a generally compact period of health care in which its principal focus is a safe and timely transition for patients between various health care settings or from one level of care to another. Examples of this transition of care can be seen when a patient transfers from different floors within a hospital or a patient is discharged from an inpatient hospital setting to a rehabilitation center or skilled nursing facility (SNF).

KEY COMPONENTS

During a transition of care, there are several key components of patient information that must be communicated. This data is crucial to ensure a safe and smooth transition for both patient and providers. The communication of this vital information can be transmitted through face-to-face communication, a telephone conversation, a secured electronic medical record, or by the patient’s paper medical record. The following is essential information needed in a transition of care:

  • Current diagnoses

  • Past medical history

  • Past surgical history

  • Medications

  • Allergies

  • Advanced directives

  • Baseline physical and cognitive assessments

  • Lab and imaging results

It is also important to note that contact information for both caregivers and providers should be included whenever possible to ensure that any gaps in information can be filled. There may be situations where other pertinent patient information may need to be included to ensure a transition of care is not fragmented and missing significant components.

CHALLENGES

Patient care has changed immensely over the past decade. It is rare that one practitioner cares for a patient across the continuum of medical settings. It is now more common for a practitioner to care for their patients in a single, specific setting. For example, a primary care provider may only see their patients in a clinical outpatient setting. If their patient is admitted to the hospital, a provider within the hospital will then most likely take over the patient’s care. Furthermore, this patient may then be transferred to an outpatient setting such as a SNF, where another provider then takes over the patient’s care. This is a common example of transitional care across health care settings. Each of these transfers has the potential to leave out crucial patient information. This can lead to medical oversights and mistakes including repeat lab tests, unnecessary diagnostic imaging, and medication errors.

PERSPECTIVE AND PROSPECTS

A well-executed transitional care can reduce unnecessary health care costs, rehospitalization, and mistakes. This transition of care must include several key components of the patient’s current medical state and past medical history. Cooperation among providers and clear communication between all of those involved in the patient’s care can create a more optimal transition of care for patients, caregivers, and providers.

For Further Information:

1 

Coleman, E. A. “Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care for Persons with Continuous Complex Care Needs.” Journal of the American Geriatrics Society, vol. 51, 2003, pp. 549-55.

2 

Coleman, E. A., and R. Berenson. “Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care.” Annals of Internal Medicine, vol. 140, 2004, pp. 533-36.

3 

Naylor, Mary. “A Decade of Transitional Care Research with Vulnerable Elders.” Journal of Cardiovascular Nursing, vol. 3, 2000, pp. 88-89.

4 

Naylor, Mary. “Transitional Care: Moving Patients from One Care Setting to Another.” American Journal of Nursing, vol. 108, Suppl. 9, Sept. 2008, pp. 58-63, doi:10.1097/01.NAJ.0000336420.34946.3a.

Citation Types

Type
Format
MLA 9th
MD, Muneeza Khan. "Transitional Care." Magill’s Medical Guide, 9th Edition, edited by Anubhav Agarwal,, Salem Press, 2022. Salem Online, online.salempress.com/articleDetails.do?articleName=MMG2022_1391.
APA 7th
MD, M. K. (2022). Transitional care. In A. Agarwal, (Ed.), Magill’s Medical Guide, 9th Edition. Salem Press. online.salempress.com.
CMOS 17th
MD, Muneeza Khan. "Transitional Care." Edited by Anubhav Agarwal,. Magill’s Medical Guide, 9th Edition. Hackensack: Salem Press, 2022. Accessed October 22, 2025. online.salempress.com.