Many factors contribute to gaps in care during critical transitions.  Poor communication, incomplete transfer of informaton, inadequate education of older adults and their family caregivers, limited access to essential services, and the absence of a single-point person to ensure continuity of care all contribute transition-associated problems (Naylor, 2002; Naylor & Keating, 2008).  The practice of nursing is closely tied to health illness transitions in a person's lifetime.  The quality of the outcomes during these transitional events is largely determined by the degree of care coordination among health care environments and proactive involvement of the patient and their families in the process, wherein a nurse plays a pivotal role.  Success in implementing evidence-based transition care strategies will help curtail preventable rehospitalizations and save health care dollars.  

Nursing Standard of Practice Protocol:  Transitional Care

Fidelindo Lim, RN, MA, Janice Foust, PhD, RN, and Janet Van Cleave, MBA, MSN, PHD

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. The text is available here.

Background and Statement of Problem
Parameters of Assessment
Nursing Care Strategies
Barriers to Successful Transition
Evaluation/ Expected Outcomes
Follow-up Monitoring
Relevant Practice Guidelines


  1. Nurses will assume a proactive role in transitional care across health care settings.
  2. Nurses will identify barriers to successful transitions and offer sustainable solutions.
  3. Increase coordination of care during transitions across health care settings amongst all members of the health care system, including the family and informal caregivers.


    1. Evidence that both quality and patient safety are jeopardized for patients undergoing transitions across care settings continues to expand (Coleman, Mahoney, & Parry, 2005).
    2. Care transitions are clinically dangerous times, particularly for older adults with complex health problems (Corbett et al., 2010).
    3. Problems encountered with poor transition process can lead to unplanned readmission and ED visits (Jacob & Poletick, 2008).
    4. Transitions are particularly vulnerable to breakdowns in care and, thus, have the greatest need for transitional care services (Naylor & Keating, 2008; Coleman et al., 2006).
    5. Family caregivers play a major—and perhaps the most important—role in supporting older adults during hospitalization and especially after discharge (Naylor & Keating, 2008).



    1. Transitional care: The American Geriatrics Society (2003) defines transitional care 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, subacute and postacute nursing facilities, the patient’s home, primary and specialty care offices, and long-term care facilities.
    2. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is based on a comprehensive plan of care and includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition.” (Coleman & Boult, 2003)
    3. Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings (Naylor & Keating, 2008).

Etiology and/or Epidemiology

    1. Situations likely to result in failed transitions include poor social support, discharge during times when ancillary services are unavailable, uncertain medication reconciliation, depression, and patients’ cognitive limitations (Cumbler et al., 2008).
    2. Medication errors related to medication reconciliation typically occur at the “interfaces of care”—when a patient is admitted to, transferred within, or discharged from a health care facility (Sentinel Event Alert, 2006).
    3. Hospital discharge practices are placing an increasing burden of care on the family caregiver (Bauer et al., 2009).
    4. RCTs of transitional care interventions has been shown to reduce hospital readmissions and health care costs (Arbaje et al., 2010; Coleman et al., 2006; Naylor et al., 2004).
    5. APN interventions in transition care has consistently resulted in improved patient outcomes and reduced health care costs (Naylor, 2002).


    1. Patient population who are most likely to benefit from transition care interventions are those who are diagnosed with one or more of the following diseases: CHF, chronic obstructive pulmonary disease, coronary artery disease, diabetes, stroke, medical and surgical back conditions (predominantly spinal stenosis), hip fracture, peripheral vascular disease, cardiac arrhythmias, deep venous thrombosis, and pulmonary embolism (Coleman, Min, Chomiak, & Kramer, 2004).
    2. Upon admission to an acute care setting, starting at the ED; patient evaluation must include referral of vulnerable older adults for transitional care services.
    3. Compliance with TJC standards in medication reconciliation will be used as one of the quality indicators and predictor in overall patient safety.

A. General guidelines that may be adapted in implementing transition care strategies based on the TMC are as follows (Bowles et al., 2002):

    1. The TCN as the primary coordinator of care to assure consistency of provider across the entire episode of care
    2. In-hospital assessment, preparation, and development of an evidence-based plan of care
    3. Regular home visits by the TCN with available, ongoing telephone support (7 days per week) through an average of 2 months postdischarge
    4. Continuity of medical care between hospital and primary care physicians facilitated by the TCN, accompanying patients to first follow-up visits
    5. Coordinate a timely appointment with patient’s primary care provider
    6. Comprehensive, holistic focus on each patient’s needs including the reason for the primary hospitalization as well as other complicating or coexisting events
    7. Active engagement of patients and their family and informal caregivers including education and support
    8. Emphasis on early identification and response to health care risks and symptoms to achieve longer term positive outcomes and avoid adverse and untoward events that lead to readmissions
    9. Multidisciplinary approach that includes the patient, family, informal and formal caregivers, and health care providers as part of a team.
    10. Physician–nurse collaboration across episodes of acute care
    11. Communication to, between, and among the patient, family and informal caregivers, and health care providers

B. Successful and safe transitions demands active patient and informal caregiver involvement. To improve patient advocacy and safety, the nurse can:

    1. Promote the “Speak Up” initiative by the TJC in 2002. The brochure “Planning Your Follow Up Care” lists patient-centered and safety-focusedquestions to be asked by the patients from their health care provider before they are discharged from the hospital (Joint Commission on Accreditation of Health Care Organization, 2002).
    2. Encourage family involvement and direct them to the “Next Steps in Care” website (see resources).
    3. Provide the patient a complete and updated medication reconciliation record. The record should include medications the patient was taking priorto admission, medications prescribed during hospitalization, and medications to be continued upon discharge (Sentinel Event Alert, 2006).
    4. Implement evidence-based interventions to reduce transition-related medication discrepancies (Corbett et al., 2010). Encourage the patient to carrytheir medication list (e.g., a copy of recent medication reconciliation from a recent hospital admission) and to share the list with any providers of care,including primary care and specialist physicians, nurses, pharmacists and other caregivers (Sentinel Event Alert, 2006).

Critical Elements of Successful Transitions

    1. Team approach and preferably nurse led (APN or specialized nurse; Coleman et al., 2006; Naylor & Keating, 2008)
    2. Active and early family involvement across transitions (Almborg, Ulander, Thulin, & Berg, 2009; Bauer et al., 2009; Naylor & Keating, 2008)
    3. Proactive patient roles and self-advocacy (Coleman et al., 2006)
    4. High-quality and individualized patient and family discharge instructions (Clark et al., 2005)
    5. Apply interventions for improving comprehension among patients with low health literacy and impaired cognitive function (Chugh, Williams, Grigsby, & Coleman, 2009), such as the National Patient Safety Foundation’s “Ask Me 3” campaign available at: http://www.npsf.org/askme3/
    6. Patient and informal caregiver empowerment through education 
    7. Commence interventions well before discharge (Bauer et al., 2009) Coleman identified elements of effective and successful transitions as follows (Coleman, 2003):
    8. Communication between the sending and receiving clinicians regarding a common plan of care
    9. A summary of care provided by the sending institution (to the next care interface providers)
    10. The patient’s goals and preferences (including advance directives)
    11. An updated list of problems, baseline physical and cognitive functional status, medications, and allergies
    12. Contact information for the patient’s caregiver(s) and primary care practitioner 
    13. Preparation of the patient and caregiver for what to expect at the next site of care
    14. Reconciliation of the patient’s medication prescribed before the initial transfer with the current regimen
    15. A follow-up plan for how outstanding tests and follow-up appointments will be completed
    16. An explicit discussion with the patient and caregiver regarding warning symptoms or signs to monitor that may indicate that the condition has worsened and the name and phone number of who to contact if this occurs.

Barriers to Successful Transitions
Coleman identified barriers to effective care transitions at three levels: the delivery system, the clinician, and the patient (Coleman, 2003).

The Delivery System Barriers

    1. The lack of formal relationships between care settings represents a barrier to cross-site communication and collaboration
    2. Lack of financial incentives promoting transitional care and accountability in fee-for-service Medicare. Although such incentives exist in Medicare managed care, most plans do not fully address care integration
    3. The different financing and contractual relationships that facilities have with various pharmaceutical companies impede effective transitions. As patients are transferred across settings, each facility has incentives to prescribe or substitute medications according to its own medication formulary
    4. This constant changing of medications creates confusion for the patient, caregiver, and receiving clinicians
    5. Neither fee-for-service nor managed care Medicare has implemented quality or performance indicators designed to assess the effectiveness of transitional care
    6. The lack of information systems designed to facilitate the timely transfer of essential information

The Clinician Barriers

    1. The growing reliance on designated institution-based physicians (i.e., “hospitalists”) and productivity pressures have made it difficult for primary care physicians to follow their patients when they require hospitalization or short-term rehabilitation.
    2. Nursing staff shortages have forced an increasing number of acute hospitals to divert patients to other facilities where a completely new set of clinicians, who often do not have timely access to the patients’ prior medical records, manages them. Skilled nursing facility (SNF) staff are also overwhelmed and do not have the time or initiative to request necessary information.
    3. Clinicians do not verbally communicate patient information to one another across care settings.

C. The Patient Barriers
Lack of advocacy or outcry from patients for improving transitional care until they or a family member is confronted with the problem firsthand.
Older patients and their caregivers often are not well prepared or equipped to optimize the care they will receive in the next setting.
They may have unrealistic expectations about the content or duration of the next phase of care and may not feel empowered to express their preferences
or provide input for their care plan.
Patients may not feel comfortable expressing their concern that the primary factor that led to their disease exacerbation was not adequately addressed.

Evaluation/Expected Outcomes
Clinician outcomes

    1. Increase nurse involvement in leading transition care teams
    2. Enhance staff training of transitional care by a multidisciplinary team
    3. Include patient’s transitional care needs during in-hospital “hand off”
    4. Improve medication reconciliation throughout all transition interfaces

Patient outcomes

    1. Improve patient satisfaction, increase involvement with their care during hospitalization and transitions of care across health care settings
    2. Increase feeling of empowerment in making health care decision
    3. Reduce rehospitalization and ED visits because of primary disease and comorbidities

Informal caregiver outcomes

    1. Improve informal caregiver satisfaction and exercise proactive roles during transitions across health care settings
    2. Increase informal caregiver participation in all transitions interface

Institutional outcomes

    1. Adopt evidence-based TCMs and provide logistic support.
    2. Provide orientation and on-going education on transitional care strategies.
    3. Introduce transitional care content into nursing core curriculum both in baccalaureate and graduate levels.


    1. Institute comprehensive and multidisciplinary transition care planning as soon as the patient is admitted and sustained throughout hospitalization
    2. Identify transition care team members and perform periodic role re-assessment, including roles of informal caregivers
    3. Incorporate continuous quality improvement criteria into transition care programs such as monitoring for rehospitalization of targeted older adult, quality of discharge instruction, and medication reconciliation
    4. Develop ongoing transitional care educational programs for both formal and informal caregivers, using high-tech and traditional media
    5. Provide orientation and ongoing education on procedures for reconciling medications to all health care providers, including ongoing monitoring (Sentinel Event Alert, 2006)
    6. Periodic “debriefing” of high-risk discharges as quality improvement strategy
    7. Improve recognition of condition changes or adverse events caused by medications
    8. Increase patient and caregivers’ knowledge concerning action steps if condition worsens including who to contact and 24-hour contact information


  1. Ongoing chart and medical records review of patients being considered for discharge or awaiting transition should reflect the quality indicators (QI) outlined in the Assessing Care of Vulnerable Elders (ACOVE) under the Continuity and Coordination of Care QI heading (Assessing Care of Vulnerable Elders-3 Quality Indicators, 2007).
  2. TJC National Patient Safety Goals (NPSG, effective July 2011) related to transitions of care include the following:

NPSG.03.06.01—Maintain and communicate accurate patient medication information. The elements of performance (EP) include the following: (TJC, 2010)

    1. Obtain information on the medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications.

Note 1: Current medications include those taken at scheduled times and
those taken on an as-needed basis.
Note 2: It is often difficult to obtain complete information on current medications from a patient. A good faith effort to obtain this information
from the patient and/or other sources will be considered as meeting the
intent of the EP.

B.    Define the types of medication information to be collected in non–24-hour settings and different patient circumstances.

Note 1: Examples of non–24-hour settings include the ED, primary care,
outpatient radiology, ambulatory surgery, and diagnostic settings.
Note 2: Examples of medication information that may be collected include
name, dose, route, frequency, and purpose.
C.    Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital to identify and
resolve discrepancies.
Note: Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified individual, identified by
the hospital, does the comparison.
D.    Provide the patient (or family as needed) with written information on the medications the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter (e.g., name, dose, route, frequency, purpose).
Note: When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include
only those medications.
E.   Explain the importance of managing medication information to the patient when he or she is discharged from the hospital or at the end of an outpa-
tient encounter.

Note: Examples include instructing the patient to give a list to his or her primary care physician; to update the information when medications are
discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information
at all times in the event of emergency situations.

Standard PC.04.02.01 (Provision of Care; U.S. Department of Health and Human Services Agency for Healthcare Research and Quality, 2011).
When a [patient] is discharged or transferred, the [organization] gives information about the care, treatment, and services provided to the [patient]
to other service providers who will provide the [patient] with care, treatment, or services.

At the time of the patient’s discharge or transfer, the hospital informs other service providers who will provide care, treatment, or services to the patient
about the following:

    1. The reason for the patient’s discharge or transfer
    2. The patient’s physical and psychosocial status
    3. A summary of care, treatment, and services it provided to the patient
    4. The patient’s progress toward goals
    5. A list of community resources or referrals made or provided to the patient

E.  Project Better Outcomes for Older Adults through Safe Transitions (BOOST)– www.hospitalmedicine.org/BOOST - provides a “toolkit” for quality improvement based on best practices, provides technical support to hospitals implementing the toolkit, and provides mentoring to promote long-term sustainability of transitional care programs (Chugh et al., 2009).
F.  Position Statement of The American Geriatrics Society Health Care Systems Committee on Improving the Quality of Transitional Care for Persons with
complex care needs must be considered in developing practice guidelines (Coleman et al., 2003)
G.  The National Transitions of Care Coalition (NTOCC) developed the guidebook Improving on Transitions of Care: How to Implement and Evaluate a Plan
(http://www.ntocc.org/Portals/0/ImplementationPlan.pdf ). This book is intended for institutions ready to make changes in the processes their facilities
use to send and receive patients. It includes an educational component about transitions of care, implementation manual, and evaluation methodology that relates to nursing home to emergency department (ED)/hospital and vice- versa. This implementation and evaluation plan aims to empower institutions to take the first step at measuring their own performance in transitions of care and identify areas for improvement (National Transitions of Care Coalition, 2008). Guidelines on hospital to home and ED to home transitions are also available from the NTOCC website: http://www.ntocc.org/Portals/0/ImplementationPlan_HospitalToHome.pdf; http://www.ntocc.org/Portals/0/ImplementationPlan_EDToHome.pdf
H.  The PPACA addresses community-based transition program under section 3026 of the law. The law provides incentive for hospital to establish and cultivate partnerships with community-based organizations to implement evidence-based transition care intervention. Proposals and programs must meet the criteria stipulated in the law (see Intervention/Care Strategies above). This criteria will lend itself to evaluation of relevant practice guidelines (Patient Protection and Affordable Care Act, 2010

There are no Resources for this topic.