Table 1 Key components of an ideal transition in care

Discharge Planning

Involves the important principle of planning ahead for hospital discharge while the patient is still being treated in the hospital.

Complete communication of information

Refers to the content that should be included in discharge summaries and other means of information transfer from hospital to post-discharge care.

Availability, timeliness, clarity and organization of information

Important because post-discharge providers must be able to access and quickly understand the information they have been provided before assuming care of the patient.

Medication Safety

This is of central importance because medications are responsible for most post-discharge adverse events.

Educating patients to promote self-management

Involves teaching patients and their caregivers about the main hospital diagnoses and instructions for self-care, including medication changes, appointments, and whom to contact if issues arise.

Coordinating care among team members

This is needed to synchronize efforts across settings and providers.

Monitoring and managing symptoms after discharge

Monitoring for new or worsening symptoms; medication side effects, discrepancies, or nonadherence; and other self-management challenges will allow problems to be detected and addressed early, before they result in unplanned healthcare utilization.

Outpatient Follow-up

Optimal follow-up with appropriate post-discharge providers is crucial for providing ideal transitions. These appointments need to be prompt (e.g. within 7 days if not sooner for high-risk patients) and with providers who have a longitudinal relationship to the patient, as prior work has shown increased readmissions when the provider is unfamiliar with the patient