Quality Update from Dr. Peter DeBlieux, UMCNO Chief Medical Officer


Transitions of care refer to the movement of patients between health care practitioners, settings, and home as their condition and care needs change. For example, a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home where he or she may receive care from a visiting nurse or support from a family member or friend.  The number of hand offs between Providers is directly linked to medical errors. Multiple transitions require a concerted effort that emphasizes effective communications about the patient’s Plan of Care.

Transitions do not always go smoothly. Ineffective care transition processes lead to adverse events and higher hospital readmission rates and costs. One study estimated that 80% of serious medical errors involve miscommunication during the hand- off between medical providers. Problematic transitions occur from and to virtually every type of health care setting.  These challenges are most common when patients leave the hospital to receive care in another setting or at home. To reduce both readmission rates and adverse events, hospitals must improve the effectiveness of transitions of care. The federal government has taken notice: Hospitals with unacceptably high readmission rates for Medicare and Medicaid patients will face financial penalties under the Patient Protection and Affordable Care Act.


Many factors contribute to ineffective transitions of patient care, and these root causes often differ from one health care organization to another. The root causes most often described in medical literature and by experts include:

Communication breakdowns – Care providers do not effectively or completely communicate important information among themselves, to the patient, or to those taking care of the patient at home in a comprehensive or timely fashion. The communication method – whether verbal, recorded, or written – is ineffective. For example, the Center for Transforming Healthcare’s hand-off communication project found these risk factors among those relating to communication:

  • Expectations differ between senders and receivers of patients in transition.
  • Culture does not promote successful hand-off (e.g., lack of teamwork and respect.)
  • Inadequate amount of time provided for successful hand-off.
  • Lack of standardized procedures in conducting successful hand-off, ex: use of SBAR (Situation, Background, Assessment and Recommendation) techniques.

Identifying high risk patients-those transitioning their care, allows providers to utilize effective hand-off tools that foster a Shared Mental Model. A Shared Mental Model allows providers, patients and their families to embrace the patient’s Plan of Care, fostering a free flow of information.  An environment where questions are encouraged and rewarded places the patient in a safer environment and enhances critical information exchange.