Transitions of Care
Navigating moves between settings
Definition
Managing the critical handoffs between care settings — ensuring continuity, avoiding gaps, and maintaining quality during vulnerable transition periods.
The danger zone
Transitions are when things fall through the cracks — medications change, instructions get lost, follow-up appointments aren't scheduled. Readmissions spike.
Coordinating handoffs
I ensure smooth transitions — confirming discharge plans, arranging home setup, reconciling medications, scheduling follow-ups, and communicating with all providers.
Continuity of care
Good transitions mean the next setting knows what happened before, understands the care plan, and can pick up seamlessly where the previous setting left off.
Related Pathways
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