Care Transitions

Patient and caregiver self-management is key to successful care transitions. This chapter presents a case study of Patient Collins which deal with care transition that was fraught with suboptimal experiences. Care transitions fall under various types. These include within settings, between settings, across health states, and between providers. It is important to differentiate what success means to the various stakeholders involved in the care transition and to understand that each element of a care transition can be evaluated for success. There are various models that exist to manage care transitions. The Care Transition Model by Dr. Eric Coleman is an effective one. There are various tools spearheaded by experts in the field that address safe care transitions’ best practices for the Interdisciplinary Care Team and the patient and/or caregiver. From the provider and health system perspective the goals of a successful care transition revolve around health outcomes, patient safety, and healthcare quality.