Care transitions and home health care

Clin Geriatr Med. 2009 Feb;25(1):135-48, viii. doi: 10.1016/j.cger.2008.11.005.


Transitions of care are becoming recognized as an important area for improvement in health care quality and patient safety. Yet there remains consistent evidence from multiple studies in varied settings of failures to complete safe, effective hand-offs from one location of care to the next. Major lapses include absent or limited clinical information and care plan content, plus errors related to medications. There are identifiable problems with half or more of the transitions that occur between care settings, and adverse consequences occur in 15 to 25 percent of patients. Undoubtedly these lapses contribute to the rates of re-hospitalization in post-acute care which affect 20 to 30 percent of patients within 60 days after hospital discharge. This article reviews models of transitional care intervention that have been tested and shown to be effective including less intensive coaching or guided care approaches, and more intensive case management strategies. Effective transitional care processes, linked with strong home care programs can reduce re-hospitalization by a third in some less intensive models and by half or more in some more intensive models.

Publication types

  • Review

MeSH terms

  • Aged
  • Continuity of Patient Care / organization & administration*
  • Home Care Services*
  • Hospitals
  • Humans
  • Nursing Homes
  • Patient Discharge*
  • Patient Readmission
  • Patient Transfer
  • Quality Assurance, Health Care