Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous...

Area of Science:

• Healthcare quality improvement
• Patient care coordination
• Health services research

Background:

• Patients with continuous complex care needs often navigate multiple healthcare settings.
• Care transitions between settings pose significant risks for poor quality and fragmented care.
• Despite prevalence, care transition challenges receive limited attention from policymakers and clinicians.

Purpose of the Study:

• To define transitional care and elucidate the problems associated with poorly executed care transitions.
• To identify barriers to effective transitional care and necessary elements for improvement.
• To propose new directions for quality improvement in transitional care.

Main Methods:

• Literature review and synthesis of existing knowledge on care transitions.
• Analysis of the nature, prevalence, and manifestations of fragmented care during transitions.
• Identification of barriers and facilitators for effective transitional care strategies.

Main Results:

• Poorly executed transitions lead to adverse outcomes for vulnerable patient populations.
• Key barriers include system-level issues, information gaps, and lack of policy focus.
• Effective transitions require coordinated efforts across delivery systems, IT, and national policy.

Conclusions:

• Enhancing transitional care is essential for improving outcomes for patients with complex needs.
• Multi-level interventions targeting delivery systems, technology, and policy are needed.
• A research agenda is proposed to advance the science of high-quality transitional care.