Care Transitions: An Evolving Science

Improving the quality and safety of care as patients transition from one care setting to another is a national healthcare priority. Despite the existence of several large randomized controlled trials showing the effectiveness of various models of hospital to home care transitions (e.g., Care Transitions Interventions, Transitional Care Intervention, Project RED), effective translation of transitional care models to clinical practice has been challenging.  For instance, provisions in the Affordable Care Act mandated that the Centers for Medicare and Medicaid Services fund care transition demonstration projects. Many of the projects of failed to be offered continuation funding as a result of either ineffective implementation (e.g., enrollment goals not met) or poor outcomes (e.g., failure to reduce hospital readmission rates). In addition, while some common interventions may improve quality and safety for all patients, there is increasing realization that a “one size fits all” care transition intervention is both ineffective and cost prohibitive. Thus, the science of care transitions continues to evolve. This symposium will present four papers that contribute to advancing the science of care transitions. First, a study exemplifying how secondary analysis of existing databases can identify patients that may benefit from specialized care transition interventions will be presented.  Second, a study that identified strategies to fulfill the unmet transitional care needs of hospitalized older adults with multiple chronic conditions will be presented. The third presentation will address a novel program that facilitates safe care transitions for patients that are homeless. Finally, lessons learned from multiple studies that tested transitional care interventions to improve medication management will be presented.  In addition to study or project findings, each presentation will identify implications for practice and research to advance this critical area of science to improve healthcare delivery, care transitions and, ultimately, patient outcomes.