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Care Transitions Support

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Karie Untiedt

Director of Quality and Patient Safety

Enhancing Care Transitions for Better Patient Outcomes

Care transitions refer to the movement of a patient from one health care setting to another, such as from a hospital to a rehabilitation facility, nursing home or home care. These transitions are critical moments in a patient’s care journey and require careful coordination to ensure continuity, safety and optimal health outcomes.

Explore Additional Patient Safety Resources

Looking for more tools and strategies to improve care transitions? MHA provides resources to help hospitals enhance patient handoffs, support self-management and reduce readmission risks.

  1. View Patient Safety Resources

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  1. The Role of Health Care Workers in Care Transitions
  2. The Importance of Engaging Patients in Care Transitions

The Role of Health Care Workers in Care Transitions

Health care providers play a vital role in engaging patients and families in transition planning. Prioritizing effective communication and support during these transitions helps to:

  • Reduce preventable readmissions by ensuring patients receive the right care in the right setting
  • Improve self-management practices, empowering patients to take an active role in their recovery
  • Enhance coordination between care teams, creating seamless handoffs and minimizing gaps in care
  • Support better long-term health outcomes, promoting stability beyond the initial hospital stay

The Importance of Engaging Patients in Care Transitions

Improving care transitions requires a holistic and patient-centered approach. Engaging patients and families in more circular, overlapping, and continual supportive care transitions helps create stronger communication channels, better follow-up care, and a more proactive health care experience.

By integrating patient and family engagement strategies, hospitals and health systems can:

  • Ensure clear discharge planning that includes medication reconciliation and follow-up care
  • Provide education on self-care practices and recognizing warning signs
  • Strengthen collaborative efforts between providers to avoid fragmented care

Through proactive and patient-focused transition planning, health care providers can improve continuity of care, enhance patient satisfaction and contribute to overall population health.

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