Issues Associated with Patient Transitions

Executive Summary

There are many issues associated with patient transitions from provider to provider, from institution to institution, and from hospitals to community settings. This article provides an overview of some issues associated with transitions. Wound complications can be one possible negative outcome that can occur when transitions are not properly managed.

For more information please see the following article: Wound Care Overview 

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Issues associated with transitions in care can arise when patients transfer from one care setting to another. On the Ontario College of Family Physicians blog, a physician recalls the issue of lack of information transfer in a transition:

A patient presented with a myocardial infarction (STEMI) and was treated at a rural hospital and then transfer to the regional center's ICU for acute management.

"I saw her a few days after discharge and her recall of events and information was patchy and unclear, as is often the case post-ICU.  She also did not have her medications list, and I had not received a discharge summary.  She saw the cardiologist six weeks following discharge, and the information in his consultation note for that visit did not include any of the recent hospital history or the medication summary and no real plan.  Clearly, he did not have the discharge summary either."

If transitions in care are not managed well from the hospital to the community there is a risk for readmission to the hospital, the risk of a repeat visit to the ER. Additionally, the lack of support decreases the patient's confidence in managing their own care.

For more information: Family Doctors and Transitions in Care 

Issues with care transitions are exacerbated due to patient comorbidities. In a study by Van Cleave, et al. it was found that comorbidities, complications, and the care process of discharge and care management are strongly linked to attributes and consequences and inform the individual's risk over time.

The schematic below indicates that there is a relationship between conditions and processes that impact the consequence of individuals with comorbidities undergoing care transitions.  


Issues associated with transitions are related to:

  • Effectiveness
    • Transitions are often cumbersome, uncoordinated, and rarely automatic.
  • Efficiency
    • Transitions are often regarded to as an afterthought.
  • Safety
    • Every time care is passed there is a chance that important information, knowledge, insight, and context could be lost, due to fractured communication.
  • Patient Centeredness
    • The healthcare system often puts responsibility for a transition onto the back of the patient (multiple pages printed out by the hospital on discharge, handed to the patient for their next doctor). There is no thought as to their capacity to follow through, especially if frail or sick.
  • Equity
    • Transitions in care are not consistent, equivalent or equitable across the province.
  • Accessible
    • When patients arrive home after being in the hospital they often experience problems with access to people and resources in follow-up. Their family doctor may not be aware of their hospitalization, for example, or there was no advice on when to see her.


For access to the full tool please see: Why are transitions so difficult?

The problems associated with care transitions must be addressed in order to improve a patients condition over time and reduce risks and complications.

For more information: Family Doctors and Transitions in Care