As hospitals and health systems across the U.S. continue to grow – mainly through mergers and acquisitions –they have become increasingly more complex to navigate. And as the options for medical care, including outpatient clinics, nursing homes, and home health services, continue to spring up overnight, so do transitional care challenges.

1 in 5

Transitional care refers to the movement of patients between practitioners, specialists, home care, and others. Unfortunately for those on this care path, these transitions do not always go as smoothly as one might hope, which leads to adverse events, hospital readmissions, and ultimately higher costs. Even within the hospital walls, frequent transitions between departments, such as from the ER to the ICU for example, lead to potentially disastrous events such as serious medication errors or inconsistent follow up after a patient leaves the hospital.

How can a system as vital as healthcare have such problems with transitions of care? While there are many factors that contribute to patients ‘slipping through the cracks,’ in the simplest of terms, there are three basic root causes that most experts would agree upon. First, there are communication breakdowns, where providers do not adequately or effectively communicate critical information to the patient and/or their family. Second, we have patient education breakdowns, when patients and their caregivers don’t sufficiently understand the medical condition or care plan because of confusing instructions or complex medication regimens. And last, but certainly not least, there are accountability breakdowns, where no one seems to be responsible for coordinated care across different settings and among various providers.

Patient Journey

The impact of these failures on patients and on the healthcare system is staggering. For example, medication errors harm millions of people each year, costing consumers billions of dollars. And according to some estimates, one in five patients discharged to home from the hospital has some sort of adverse event within three weeks of discharge, many of which could have been avoided. Even when the patient escapes these arduous processes relatively unscathed, rarely are they thrilled with their overall experience or satisfied with the service they receive. For patients and providers alike, there are seemingly endless opportunities for improvement.

So how are we confronting these broken transitions and lack of care coordination? A number of attempts over recent years aim at improving communication between patients and caregivers, standardizing information with technology, establishing points of accountability for sending and receiving care, and developing performance measures to encourage improvement and align incentives. Ultimately, engagement between the provider and the patient is necessary for seamless transitions of care to become a reality.


Abbott and Costello gave us a very funny example that I believe illustrates the confusion all too often experienced by patients traversing the healthcare journey in their standup routine called “Who’s on First”. If you haven’t seen it, I highly recommend it – it’s a bit that will be funny for all time! While there’s nothing funny about a flawed healthcare system, or a patient’s struggles during difficult and often frightening times, the moral of the story still holds true. We need to understand where patients are in their journey - who’s on first - and how to get them to their next step, in order to improve healthcare quality - one patient at a time.

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