Home Health & Hospice

Understanding care transitions and coordination of care

Homecare Insider, July 15, 2013

A care transition is defined as the movement of patients from one healthcare provider or setting to another as their condition and care requirements change during the course of an acute or chronic illness.

An example of a care transition would be if a patient received care in a hospital during an acute phase of illness, then moved to a skilled nursing facility and finally returned home with a homecare agency. A care transition would be each of these changes of provider and/or setting.

To have a successful transition of care, the first step is to identify, coordinate, and optimize existing resources. This step would be defined as care coordination. Care coordination encompasses the assessment of a patient's needs, development and implementation of a plan of care, and evaluation of the care plan.

Although a transition of care refers to the actual transition between two particular care settings, care coordination involves the interaction of providers and other stakeholders across a variety of care settings to ensure optimal care for a patient. Every transition of care involves care ­coordination.

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