Care Transitions From Inpatient to Outpatient Settings: Ongoing Challenges and Emerging Best Practices

Abstract

Care transitions occur every time a patient changes levels of service, location, or with each shift change or transfer of care. The complexities involved in transitions of care make these time periods particularly susceptible to medical errors, placing patients at risk. Improving care transitions affects all patients in all settings, and has the potential to reduce adverse events, improve quality of care, and produce medical cost savings. This article is a focused review of transitions in care from the inpatient to ambulatory care settings. Underlying challenges and sources of errors are identified, and possible solutions and interventions are explored. Specific challenges to the pediatric population are also examined in detail.

The Family Perspective on Hospital to Home Transitions: A Qualitative Study

“…There is evidence, primarily in newborn and high-risk adult populations, that postdischarge home nurse visits or phone calls can improve outcomes such as decreased health care utilization. [35][36][37][38][39][40][41][42] Such evidence, in combination with our findings, reinforces the need for further study of visits or calls that are tailored to meet the needs of families after hospital discharge. Determining their impact on both family-centered outcomes in addition to health care utilization is critical.…”

Pediatric hospital discharge interventions to reduce subsequent utilization: A systematic review

“…There are a number of existing discharge transitional care frameworks from prior studies and professional societies . The Stepping Up to the Plate (SUTTP) alliance, a collaborative of 9 professional organizations, including the American Academy of Pediatrics, introduced 1 such framework in 2007.…”

Preoperative “NPO” as an opportunity for diabetes screening

“…In the era of Accountable Care Organizations (ACO) and need to improve transitions of care, diagnosis and management of diseases across the continuum from ambulatory to inpatient care remains of paramount importance. 1,2 Opportunities for screening have typically been viewed as the responsibility of the ambulatory primary care provider (PCP), yet in an ACO model, patients who present more frequently to a hospital as opposed to a clinic are still the responsibility of the ACO, and therefore opportunistic screening for certain diseases by hospitalists and other inpatient providers is a possibility that may merit further investigation. This ''opportunistic'' rationale has already been used to advocate for pneumococcal and influenza vaccination prior to discharge in hospitalized patients, but has not been well investigated in chronic disease screening.…”