Transitions in care - transitions between settings

Overview

Care transitions between settings (hospital to home, hospital to residential care, between different care facilities) carry substantial risk of adverse events - medication discrepancies, incomplete information transfer, and gaps in follow-up arrangement are common, well-documented problems at this specific transition point, distinct from but related to practitioner-level transitions
Among the highest-risk points in the overall care continuum, with hospital discharge in particular associated with elevated rates of preventable adverse events and readmission in the immediate post-transition period

Setting transitions combine multiple simultaneous risk factors - change of treating team, change of care environment/support level, and often medication regimen changes made during the preceding episode of care - this combination of factors converging at a single point explains why setting transitions carry disproportionately elevated adverse event risk compared with more stable periods of ongoing care within a single setting

Structured discharge planning (medication reconciliation, clear follow-up arrangements, patient/carer education, and confirmed receiving service arrangements before the transition occurs) directly addresses the multiple compounding risk factors present at this transition point
Post-transition follow-up contact (phone call or early appointment) within a short interval after discharge can identify and address emerging problems before they escalate to an adverse event or readmission
Structured discharge planning processes (medication reconciliation, follow-up arrangement confirmation, patient/carer education) as standard practice for any significant setting transition, particularly hospital discharge
Early post-transition follow-up contact to proactively identify and address emerging problems

Hospital discharge as a particularly high-risk transition point, medication reconciliation at setting transitions (see ), structured discharge planning process components, early post-discharge follow-up contact value

Setting transitions (particularly hospital discharge) combine multiple simultaneous risk factors - team change, environment/support level change, and often medication regimen changes - all converging at a single point, which explains why this specific transition carries disproportionately elevated adverse event and readmission risk, and why structured, comprehensive discharge planning addressing each of these factors is a recognised, evidence-based patient safety priority

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