Transition of care is the critical handoff that occurs when a person moves between care settings—hospital to home, emergency department to primary care, or acute care to rehabilitation. When this handoff is coordinated, people understand their plan, medications are safe, and providers work from the same playbook. When it’s not, the result can be avoidable readmissions, adverse drug events, and poor experience for patients and families. This page explains what excellent transition of care looks like and how transition care management (TCM) operationalises it.
High-performing organisations treat transitions as a designed service, not an afterthought. That starts with a shared, documented pathway: who does what, by when, using which tools, and how we know the handoff worked. It spans clinical details (diagnosis, test results, pending referrals), practicalities (equipment, transport, home support), and the human side (health literacy, confidence, cultural considerations). The goal is simple: the next team—and the person receiving care—should never have to guess.
Transition care management turns the handoff into a repeatable workflow. A typical TCM model includes four pillars:
Clear ownership. Assign a named coordinator—often a nurse, pharmacist, or care navigator—who is accountable from discharge through the first community follow-up. Ownership prevents “everyone and no one” from being responsible.
Timely communication. Discharge summaries, medication lists, and care plans must reach the next clinician quickly and in a usable format. Secure messaging or HIE connectivity helps; so does a standardised template with the essentials highlighted.
Medication safety. Reconciliation is non-negotiable. Compare pre-admission, in-hospital, and discharge lists; flag high-risk drugs; and provide plain-language instructions. Whenever possible, involve a pharmacist and confirm that prescriptions are filled.
Patient and caregiver activation. Education should be teach-back-based and culturally appropriate. Provide one-page action plans covering red-flag symptoms, who to call, and what to do. Offer digital options (SMS, app, portal) without assuming digital literacy.
When organisations operationalise these pillars, TCM becomes a bridge between settings. It reduces friction for clinicians and lowers anxiety for people leaving the hospital. Crucially, it focuses effort on those at highest risk by using simple risk stratification—diagnosis, comorbidities, social support, prior utilisation—to target outreach and resources.
To bring transition care management to life, map the workflow end-to-end:
Pre-discharge: Start the plan early. Identify the responsible primary care or community clinician. Book the follow-up before discharge. Confirm contact details and preferred communication channels.
Day of discharge: Send a succinct discharge packet electronically (summary, meds, pending tests, referrals). Hand patients a readable version, ideally in their language, and demonstrate key self-care tasks (wound care, devices).
Post-discharge outreach: Use a structured call or message to check understanding, confirm medications, and screen for barriers (transport, food, caregiver support). Document issues and close the loop with the receiving clinician.
First visit in the community: Review the hospital course, reconcile medications again, check vitals and symptoms, and update the care plan. Schedule follow-ups and connect to community resources (home health, social services, pharmacy reviews).
Ongoing navigation: For high-risk individuals, maintain touchpoints for several weeks. Simple nudges—appointment reminders, refill prompts, red-flag check-ins—can prevent deterioration.
Technology supports, but does not replace, good design. Prioritise tools that automate handoffs (EHR-to-EHR, secure messaging), drive adherence (reminders, remote monitoring for specific conditions), and surface risks (alerts for missed follow-ups or unfilled prescriptions). Keep equity in view: always offer non-digital options and interpreter support.
Measurement turns intention into improvement. Track a tight set of indicators tied to transition care management:
Process reliability: proportion of discharges with confirmed follow-up appointment; rate of completed post-discharge outreach; timeliness of discharge summary delivery.
Safety and quality: medication-reconciliation completion; discrepancies found and resolved; adverse events within 30 days.
Utilisation and outcomes: unplanned ED visits and readmissions; length of stay on readmission; condition-specific outcomes where relevant.
Experience and equity: patient-reported confidence in the care plan; caregiver burden; outcomes by language, age, and deprivation to spot disparities.
Governance matters. Maintain a standard operating procedure for TCM, review a sample of cases weekly, and run brief “after-action” huddles for any bounce-backs. Align documentation with regulatory and privacy requirements in your region, and ensure role-based access to shared data. Where multiple organisations are involved, establish a lightweight data-sharing agreement and a single escalation path for problems that arise after discharge.
Excellent transition of care is about reliability, not heroics. By embedding transition care management—clear ownership, timely communication, medication safety, and patient activation—health systems can deliver safer, calmer handoffs and better outcomes across the continuum.
