Transitions of Care

What is a Care Transition?

A care transition happens when an older patient moves from one health care provider, level of care, or setting to another. Care transitions can happen inside hospitals. For example, a patient may move from the emergency room to a hospital room, and then to an intensive care unit (ICU). Older adults may also move from the hospital to a nursing home or to home health care. Or they may return home with no extra services.

Older adults are more likely to receive poor care or experience harmful events during these transitions. To prevent these problems, health care teams should work together to manage transitions of care. This team approach can lead to better health outcomes for older adults, their caregivers, and their health care providers.

The Risks of Poor Care Transitions

Care transitions happen often and can be very complex. 

  • About 40 percent of older adults have more than two care transitions within 30 days of leaving the hospital. 
  • One study found that 22 percent of Medicare patients experience some type of care transition. About half go back home, and the other half go through a series of care transitions.

There is no set pattern for these transitions. But they can cause serious problems for older adults. For example, post-hospital syndrome occurs when an older adult faces a high risk of new health problems right after leaving the hospital. These problems add to the challenges of recovering from the illness that caused the hospital stay. Some care strategies can help reduce these risks.

Common dangers during care transitions 

These include medication errors and missing or incomplete information shared between care settings. These errors can lead to:

  • Delayed diagnosis
  • Duplicate medical services
  • Less satisfaction for both patients and health care providers

Older adults face a higher risk of safety problems for several reasons. They are more likely to use hospitals and emergency rooms, and they often face challenges getting the health care services they need.

Methods of Improving Care Transitions

Some common barriers to good care transitions include:

  • Hospitals and other care settings that discharge patients without following the care plan.
  • Poor communication among health care providers, and not enough education for the older adult and their caregivers.
  • Older adults with disabilities or those who live alone and do not have enough support to manage their care.
  • Costs that are too high for the older adult.
  • Health materials that are hard for older adults to read or understand.

Programs to improve care transitions for older adults have been studied and developed. Programs that work well include:

  • Assessment, which looks at the patient’s mental health, ability to move around, medications, medical history, and what matters most to them.
  • Thorough discharge planning that addresses the needs of the patient and their caregivers.
  • Education for the older adult and caregivers, and sharing of important information they will need.
  • Sharing information with the health care professionals who will take over the older adult’s care.
  • A care transition guide who checks on the older adult throughout the transition.
  • Involving caregivers in the process.
  • Home health services.
  • Supporting the older adult and caregivers to take an active role in their care.
  • Follow-up care and support after discharge.
  • Tracking quality measures tied to patient outcomes, such as patient and caregiver satisfaction with care, and how quickly complete information is shared after transfer.

Discharge Planning

Medicare requires hospitals to offer discharge planning services to patients in the hospital. Trained nurses or social workers provide this service. They must give patients who are being discharged information about their options for skilled nursing facility or home health services after leaving the hospital, if needed.

The Center for Medicare Advocacy provides guidelines to help Medicare patients take an active role in discharge planning. It also helps them understand the options and services available to them.

The Centers for Medicare and Medicaid Services also offers a tool for Medicare patients to compare staffing information and care quality at Medicare-certified skilled nursing facilities across the U.S. Patients can view comparison data, including hospital readmission rates.

Discharge and Older Adults' Medications

The medication list is a key part of discharge from the hospital. This list should include:

  • Each medication and what it is used for
  • A schedule for slowly stopping any medications that need to be tapered
  • Lab tests needed to monitor how medications are working
  • New medications that were started during the hospital stay
  • Home medications that should no longer be taken

Communication Between Older Adult, Care Partners, and Receiving Health Care Team

Older adults who leave the hospital may go home or to another care facility.

After discharge to home, the older adult and any caregivers need to know about:

  • Follow-up appointments that are needed
  • Warning signs or symptoms of health problems to watch for, and who to call if problems occur
  • A list of needed medications

Older adults being discharged to another care facility need:

  • Information about what the new facility is and how it works
  • The name of the new attending doctor (if known) and how often they will see health care providers

Tools are available to help older adults and caregivers decide what type of care they want after leaving the hospital, understand discharge instructions, find medication mistakes, and improve communication between care sites at discharge. For example, visit the Care Transitions website. 

Post Hospital Settings of Care

Health care professionals and older adults have several choices when an older adult leaves the hospital:

  • Home with support from family
  • Home with home health or hospice care
  • A care facility, which may include assisted living, a skilled nursing home, an acute rehabilitation hospital, long-term acute care, or inpatient hospice

Medicare has rules about when it will cover these services:

  • People getting home health care must be homebound and need part-time care.
  • Skilled nursing facility care is likely covered when patients need a skilled service, such as nursing or physical therapy. Coverage only applies after a qualifying hospital stay.
  • People getting acute rehabilitation in a facility must have major rehabilitation needs and the ability to get better.
  • Long-term acute care, also called “chronic hospitalization,” is for people who need hospital-level care over a long period. This may include a breathing machine (mechanical ventilation), IV medications, tube feeding, complex wound care, and frequent health monitoring.

 

Last Reviewed and Updated: October 2026 
By: AGS/HiAF Public Education Committee, HealthinAging.org Content Reviewers 

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