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Consumer Corner

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 Click this button to listen to interview

Jeffery A. Kerr, DO, CMD

Missouri Click this button to listen to interview

Peter A. Kovalszki, MD, CMD

Michigan Click this button to listen to interview

Anthony J. Lechich, MD

New York Click this button to listen to interview

Dan Osterweil, MD, MscEd, CMD

California Click this button to listen to interview

Alec Pruchnicki, MD

New York Click this button to listen to interview

Robert Schreiber, MD, CMD

Massachusettes Click this button to listen to interview

James Yates, MD, CMD

Alabama Click this button to listen to interview
*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 Chapters Work with QIOs on Transitions

AMDA Leads on Transitions Improvements

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

Panel Reveals Means to Better Transitions

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