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How To Improve Transitional Care Communication

April 13th, 2021
April 13th, 2021

Transitional care plays an important role for anyone ending a hospital stay and headed for further recovery in the home or other care facility. According to an article in the American Journal of Nursing, this area of care “encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings. High-quality transitional care is especially important for older adults with multiple chronic conditions and complex therapeutic regimens, as well as for their family caregivers” (Naylor & Keating, 2009).

The Agency for Healthcare Research and Quality (AHRQ) shares that care transitions “increase the risk of adverse events due to the potential for miscommunication” as responsibility for care continuity is given to new parties. One reason is that every hospital discharge is a complex process representing a time of significant inherent vulnerability for patients. Safe and effective transfer of responsibility for a patient’s medical care relies on effective provider communication with patient comprehension of discharge instructions.

Communication Best Practices for Care Transitions

The National Transitions of Care Coalition identifies seven opportunities to use communication as a tool for improved transitional care. Here they are with some of their component activities that make up a better transitional care model:


  1. Provide Medication Management

    Ensure safe use of medications through education of the patient, family and caregivers.  Some ways to do this involve:

    • Teach back methods to establish understanding of medication plan
    • Explain what medications to take, emphasizing any changes in the regimen
    • Review each medication’s purpose, how to take each medication correctly, and important side effects to watch out for
    • A medications management plan that includes how to get them, confirmation that all parties understand, and an integrated approach between physicians and pharmacist
  2. Conduct Transition Planning

    Facilitate the move from one level care to another, guided by an experienced transition practitioner who is part of the healthcare team. Components include:

    • Assessment of home environment and patient care needs after discharge
    • Education about self-care management and expectations tailored to patient and family literacy level
    • Standardized discharge/transition documents to patient and new care setting, as applicable
  3. Provide Patient and Family Education

    Education and counseling of patients and families works to enhance their active participation in their own care including informed decision making. Features include:

    • Understanding what worsening condition looks like, especially ‘red flags’ and what to do about it
    • Tailored education to health literacy
    • Ensure understanding by having recipients explain it back to you
  4. Oversee Information Transfer

    Share important care information among patient, family, caregiver and healthcare providers in a timely and effective manner. Recommendations include:

    • Timely transfer of critical patient information, preferably within 24 hours.
    • Use of specifically designed tools, like a Transfer Tool, Transition Record, or Transition Summary
    • Care coordinators to facilitate provider-patient communication
  5. Ensure Follow-Up Care

    Ensure that Patients and families get timely access to key healthcare providers after an episode of care as required by the patient’s condition and needs. Strategies include:

    • Confirmation of any primary care or specialist appointments
    • Schedule any necessary follow-up testing before discharge
    • Access to a 24-7 help line
    • Expedited access to post-acute care
    • RN follow up call immediately post-discharge to monitor patient condition
    • Frequent contact helps detect subtle changes in patients’ conditions and quick reactions
    • to changing medical, functional, and psycho-social problems
  6. Facilitate Healthcare Provider Engagement

    The appropriate provider should demonstrate ownership, responsibility, and accountability for the care of the patient and family/caregiver at all times. Activities include:

    • Identify personal physician for ongoing relationship
    • Care plans that align with accepted evidence-based guidelines
    • Coaching patient on self-care
    • Written instructions given to patient and family
    • Facilitate communication among providers about patient status and progress
    • Coordinated approach to patient care
  7. Demonstrate Shared Accountability across Providers and Organizations

It is possible to enhance the transition of care process through securing accountability for care of the patient by both the healthcare provider (or organization) transitioning and the one receiving the patient. This involves:

  • Clearly communicating the patient’s plan of care, and being available for any questions afterwards
  • Ensuring continuity of provider responsibility for patient care at all times
  • Requiring an acknowledgement that plan of care has been received and understood

Improving transitional care is one of the ways healthcare organizations can work to avoid unnecessary readmissions, which drive up the cost of healthcare. Organizations across the care continuum are paying lots of attention to improving care transitions, especially now that higher acuity patients in recovery and rehabilitation are commonly being found outside of hospitals. Learn about HealthStream’s solutions for workforce development across the continuum of care.

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