The care transitions intervention: a patient-centered approach to ensuring effective transfers between sites of geriatric care

Home Health Care Serv Q. 2003;22(3):1-17. doi: 10.1300/J027v22n03_01.


During an episode of illness, older patients may receive care in multiple settings; often resulting in fragmented care and poorly-executed care transitions. The negative consequences of fragmented care include duplication of services; inappropriate or conflicting care recommendations, medication errors, patient/caregiver distress, and higher costs of care. Despite the critical need to reduce fragmented care in this population, few interventions have been developed to assist older patients and their family members in making smooth transitions. This article introduces a patient-centered interdisciplinary team intervention designed to improve transitions across sites of geriatric care.

Publication types

  • Clinical Trial
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Chronic Disease / therapy
  • Continuity of Patient Care / organization & administration*
  • Efficiency, Organizational
  • Episode of Care
  • Health Services Needs and Demand
  • Health Services for the Aged / organization & administration*
  • Home Care Services / statistics & numerical data
  • Humans
  • Patient Care Team
  • Patient Discharge*
  • Patient Transfer / organization & administration*
  • Patient-Centered Care / organization & administration*
  • Skilled Nursing Facilities / statistics & numerical data
  • United States