The health care system is complex and poorly connected, and patients often are not well prepared to navigate it, especially during transitions. "Care transition" refers to the movement of patients from one health care practitioner or setting to another as their condition and care needs change. A patient might be treated by a family physician, then be hospitalized, and later spend time in a nursing home before going home. Communication of information including treatment plans, medication instructions, clinical information, and patient preferences across care settings is often minimal at best. As patients encounter multiple caregivers, information can be confusing, contradictory, or missing critical elements.

While much attention has been focused on medical errors in institutional settings, serious problems exist as a result of movement between settings, and these problems are often overlooked. Most health care providers practice in only one setting and are not familiar with the specific requirements of other settings. Because health care providers usually do not follow the patient to the next level of care, the risk for error and problems with continuity of care increase with care transitions. Elders and others with chronic diseases are at greatest risk.

Appropriate care transitions take into account the needs of patients, their health goals and wishes, appropriate logistical arrangements, patient and family education about expectations and next steps, and coordination between health care providers at both settings. Evidence-based research indicates that better management of patient transitions improves continuity of care, reduces error and delay, and increases patient control of health decisions.

CHCF's Better Chronic Disease Care program is funding several care transition projects:

• Coleman Care Transitions Intervention pairs hospitals with community agencies in 10 locations in California to support patients with specific tools and skills to take a more active role in their health care. Read testimony by CHCF Senior Program Officer Kate O'Malley before the California legislature.
• Physician Orders for Life-Sustaining Treatment (POLST) uses a standardized medical order form printed on brightly colored paper for health care professionals to indicate which types of life-sustaining treatment a seriously ill patient wants or doesn't want if their condition worsens. CHCF has issued a request for proposals (RFP) to implement POLST in local communities.
• Transitional Care for High-Risk Elders takes a proven approach to reducing preventable rehospitalization of high-risk elders and tests whether similar outcomes can be achieved using a lower-cost staffing model (using registered nurses instead of nurse practitioners).