Transitions of Care

Transitions of care involve the movement of a patient between care settings and the transfer of information with them to facilitate a seamless continuum of care and to enable patients’ wishes to be followed - no matter where in the continuum of care they are. This is an important issue, as care for today’s elderly people is more complex than ever. It may involve a wide variety of care settings over time including community-based care, home care, hospital care, sub-acute care, rehab, skilled nursing care, assisted living, and hospice. This care may involve a wide range of treatments and services, medications, practitioners, caregivers, and payors. As an elderly person gets sicker or gets better, he or she may move from setting to setting, such as from a hospital to a nursing home or rehabilitation facility or from home to an assisted living facility. It is important that these transitions of care between settings are handled smoothly and effectively.

AMDA physicians in regions throughout the country have information and guidance on this topic. You can listen to these practitioners offer insights about transitions of care and how to ensure smooth transitions across the care continuum.

Daniel Bluestein, MD, CMD	Minnesota
Jeffery A. Kerr, DO, CMD	Missouri
Peter A. Kovalszki, MD, CMD	Michigan
Anthony J. Lechich, MD	New York
Dan Osterweil, MD, MscEd, CMD	California
Alec Pruchnicki, MD	New York
Robert Schreiber, MD, CMD	Massachusettes
James Yates, MD, CMD	Alabama
*Requires a program that plays MP3 audio files

"Caring for Consumers" clip and copy advice sheets, designed for residents/patients, family members, and future consumers of long term care services, include an introduction to the topic, tips for addressing the issue and enhancing care, a list of questions to ask the physician, and a list of additional resources. Feel free to print and use when speaking to your family and physician.

Smooth Moves Between Care Settings

Helpful Links

AMDA Leads on Transitions Improvements

Transitions Coaching Is Good for Patients: Health Care Workers Can Empower Residents, Patients, and Families to Be Self Advocates

Change Is Needed in Care Transitions

Panel Reveals Means to Better Transitions