Transitional care is the coordination and continuity of a patient’s health care during his or her transfer from one healthcare setting to another, or even back home. Transitional care is frequently required for older adults who need various health care services in a number of different environments.
During a patient’s transfer or transition between levels of health care service, individuals, especially older patients, are at greater risk for poor outcomes due to the potential for medication errors or errors in communication. Most transitional care study has occurred in the movement from hospitalization to other settings, such as nursing facilities, rehabilitation facilities, or the patient’s home. Transitional care is also required for younger patients with chronic conditions, especially as individuals move out of pediatrics and into adult services.
Currently, there is only one national measure of care in transitional care. That the Care Transitions Measure (CTM), a 15-item survey administered to patients at their discharge from a hospital. Patient responses are said to predict the likelihood of a return to the ER or hospital. Care Transitions Intervention (CTI) is a coaching strategy designed to assist patients in the resumption of self-care, helping individuals to become comfortable in managing medications and understanding what changes would necessitation contacting a healthcare provider.