Core Competencies

3.24 Transitions of Care

© 2017 Society of Hospital Medicine

The term “transitions of care” refers to specific interactions, communication, and planning required for patients to safely move from one care setting to another. These transitions apply not only to transfers of care between the inpatient and outpatient settings but also to handoffs that occur within facilities (eg, service to service) and communities (eg, inpatient to subacute rehabilitation). Ineffective transitions of care are associated with adverse events, and nearly 20% of patients experience adverse events (many of which are preventable) within 3 weeks of hospital discharge.1,2 Hospitalists should promote efficient, safe transitions of care to ensure patient safety, reduce loss of information, and maintain the continuum of high-quality care.

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Hospitalists should be able to:

  • Describe the relevant parts of the medical record that should be retrieved and communicated during each care transition to ensure patient safety and maintain the continuum of care.
  • Describe the importance and limitations of patient transition processes.
  • Describe ancillary services that are available to facilitate patient transitions.
  • Compare postacute care options for patients.
  • Explain the strengths and limitations of different communication modalities and their role in patient transitions.
  • Explain elements of a high-quality patient handoff.
  • Recognize the value of real-time interactive dialogue among clinicians during care transitions.
  • Describe the characteristics of a high-quality discharge summary document.
  • Recognize the impact of care transitions on patient outcomes and satisfaction.


Hospitalists should be able to:

  • Use the most efficient, effective, reliable, and expeditious communication modalities appropriate for a patient’s care transition.
  • Communicate and synthesize relevant medical information to and from referring healthcare providers into a cohesive care plan.
  • Develop a care plan early during hospitalization that anticipates care needs beyond the inpatient care setting.
  • Prepare patients and families early in the hospitalization for anticipated care transitions.
  • Access available ancillary services that can facilitate patient transitions.
  • Expeditiously inform the primary care provider about significant changes in patient clinical status.
  • Inform receiving healthcare providers of pending tests and determine responsibility for the follow-up of pending results.
  • Select an appropriate level of postacute care that is best suited to the patient’s needs.
  • Incorporate patient preferences and use shared decision-making in the selection of postacute care.
  • Anticipate and address language and/or literacy barriers to patient education.
  • Communicate with patients and families to explain the patient’s condition, ongoing medical regimens and therapies, follow-up care, and available support services.
  • Communicate with patients and families to explain clinical symptomatology that may require medical attention before scheduled follow-up.
  • Coordinate multidisciplinary teams early during hospitalization to facilitate patient education, optimize patient function, and improve discharge planning.
  • Lead, coordinate, and/or participate in initiatives to develop and implement new protocols to improve or optimize transitions of care.
  • Lead, coordinate, and/or participate in the evaluation of new strategies or information systems designed to improve care transitions.


Hospitalists should be able to:

  • Engage in a multidisciplinary approach to care transitions, including nursing, rehabilitation, nutrition, pharmaceutical, and social services.
  • Engage stakeholders in hospital initiatives to continuously assess the quality of care transitions.
  • Maintain availability to discharged patients for questions during discharge and between discharge and the follow-up visit with the receiving physician.


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