A N EXPANDING EVIDENCE
base demonstrates that serious
deficiencies in quality
exist for patients undergoing
transitions across
sites of care. Qualitative studies1-7 produced
consistent results, demonstrating
that patients are often unprepared for their
self-management role in the next care setting,
receive conflicting advice regarding
chronic illness management, are often unable
to reach an appropriate health care
practitioner who has access to their care
plan when questions arise, and have minimal
input into their care plan.
Quantitative studies8-15 documented
that quality and patient safety are compromised
during the vulnerable period
when patients transition between different
settings because of high rates of medication
errors, incomplete or inaccurate information
transfer, and lack of appropriate
follow-up care. During care transitions, patients
receive medications from different
prescribers, who rarely have access to patients’
comprehensive medication lists.16,17
Collectively, these types of problems conspire
to increase rates of recidivism to highintensity
care settings when patients’ care
needs are not met, leading to greater health
care costs.9,12,15,18-21 National 30-day readmission
rates among older Medicare beneficiaries
range from 15% to 25%