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Discussion – Care Transitions

Discussion – Care Transitions

Transitioning care from one level to another, such as from the hospital to primary care follow-up or from long-term care to home care, is a critical juncture in a patient’s healthcare journey. This transition is riddled with various barriers and challenges, some of which I have encountered while working in an emergency room.

One significant barrier is ineffective communication and information exchange among healthcare providers. Inadequate sharing of patient information, including medical history, treatment plans, and medication lists, can lead to errors and misunderstandings. For example, when a patient is discharged from the hospital for primary care follow-up, there is a risk of duplicate testing, medication differences, and missing follow-up appointments if the primary care physician needs to be better informed about the hospitalization specifics. (Sharma et al., 2023). This can negatively impact patient safety and continuity of care.

Another common challenge is coordinating services and resources, especially when transitioning from a long-term care facility to home care. Patients often require support services like home health nursing, physical therapy, and medical equipment. Coordinating these services effectively can be complex and time-consuming (Sharma et al., 2023). Without a seamless process, patients may experience delays in receiving essential care and equipment, potentially resulting in worsened health or preventable readmissions.

In my experience, a procedure that has shown promise in improving care transitions is the implementation of care transition teams or care coordinators. These professionals are responsible for carefully managing all aspects of the transition. They communicate with both the sending and receiving healthcare providers, ensure the patient’s health information is shared accurately, and facilitate the scheduling of follow-up appointments and necessary services. By serving as a bridge between different levels of care, care transition teams help streamline the process and reduce the likelihood of errors. The impact of such a procedure on patient safety is significant. By improving communication and coordination, care transition teams can reduce the risk of medical errors, medication discrepancies, and missed appointments. This, in turn, can lead to better patient outcomes, decreased readmission rates, and enhanced patient satisfaction (Finkelstein et al., 2020). Patient safety is not only about preventing medical errors but also about ensuring that the patient’s overall well-being and quality of care are maintained during transitions.


Finkelstein, A., Zhou, A., Taubman, S., & Doyle, J. (2020). Health care hotspotting—a randomized, controlled trial. New England Journal of Medicine382(2), 152-162. 10.1056/NEJMsa1906848

Sharma, D., Singh Aujla, G., & Bajaj, R. (2023). Evolution from ancient medication to human‐centered Healthcare 4.0: A review on health care recommender systems. International Journal of Communication Systems36(12), e4058.


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Discussion - Care Transitions

Discussion – Care Transitions

Step 1 Post a response to the discussion board.

Respond to the following prompts and, if it’s relevant, include your own personal experience:

What are some barriers and challenges to the transition of care from one level to another? Describe at least two. Examples: transition from hospital to primary care follow-up or long-term care to home care.
Give an example from your experience or the literature of a procedure aimed at improving the process of care transitions. What impact do you suppose it will have on patient safety?
Step 2: Read and respond to two other students’ posts

Read other students’ posts and respond to at least two of them. Use your personal experience, if it’s relevant, to help support or debate other students’ posts. If differences of opinion occur, debate the issues professionally and provide examples to support your opinions.

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