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PRINTED FROM the Encyclopedia of Social Work, accessed online. (c) National Association of Social Workers and Oxford University Press USA, 2016. All Rights Reserved. Under the terms of the applicable license agreement governing use of the Encyclopedia of Social Work accessed online, an authorized individual user may print out a PDF of a single article for personal use, only (for details see Privacy Policy).

date: 19 November 2017

Abstract and Keywords

Transitions in care occur when a patient moves from an institutional setting, such as a hospital or nursing home, to home or community, often with the hope or expectation of improving health status. At the very least, patients, clinicians, and caregivers aim to achieve stability and avoid complications that would precipitate a return to the emergency department (ED) or hospital. For some groups of vulnerable people, especially the very old and frail, such transitions often require specific, targeted coaching and supports that enable them to make the change successfully. Too often, as research indicates, these transitions are poorly executed and trigger a cycle of hospital readmissions and worsening health, even death. In recognizing these perils, organizations have begun to see that by improving the care transition process, they can improve health outcomes and reduce costs while ensuring safety, consistency, and continuity. While some of this improvement relies on medical care, coaching, social services and supports are often also essential. Lack of timely medical follow-up, transportation, inadequate nutrition, medication issues, low health literacy, and poverty present barriers to optimal health outcomes. By addressing social and environmental determinants of health and chronic disease self-management, social workers who make home visits or other proven timely interventions to assess and coach patients and their caregivers are demonstrating real results. This article describes care transitions interventions, research into barriers and opportunities, and specific programs aimed at improvement.

Keywords: care transitions, readmissions, discharge planning, social work, community-based care transitions, Coleman model, CTI, HomeMeds

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