Why are transitions so diffcult?


Key Questions: What makes patient transitions so difficult and how can it be improved across various transitions of care?

This tool provides information about issues associated with transitions in care. The tool is a post on Health Quality Ontario.

For more information on wound care see the following article: Wound Care Overview


Issues associated with transitions are related to:

  • Effectiveness
  • Efficiency
  • Safety
  • Patient Centeredness
  • Equity 
  • Accessible
Link to Tool: 

Why are transitions so difficult?


  • Transitions are often cumbersome, uncoordinated, and rarely automatic. Moving patient information in a quick and standardized way improves effectiveness. 


  • Transitions are often regarded to as an afterthought.
  • Creating a process for handover that is widely and consistently adopted, will allow it to be more prompt and less time-consuming.


  • Every time care is passed there is a chance that important information, knowledge, insight and context could be lost, due to fractured communication.
  • Solutions could be as simple as a phone call or as technical as moving a complete electronic record from one provider to another. 

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.
  • Some hand-offs happen without the patient at all, and this too can be a problem. The job is considered done when a summary is sent by regular mail to a doctor “on record”. This may not even be the correct physician for follow-up, and often it arrives too late. 


  • Transitions in care are not consistent, equivalent or equitable across the province. Interestingly they work best in locations where there are tight provider relationships and there is a sense of shared responsibility. 


  • 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.
  • Access is improved if the patient’s primary care provider knows immediately that he has been admitted or discharged. Having complete information makes it is much easier to plan nursing care or home visits, and access is vastly improved.

A few solutions include maintaining key clinical relationships, with attention paid to direct communication. Integrated technology can address some of the issues related to standardization and ensuring that information is transferred automatically. 

Contact Person/Organization: 

Health Quality Ontario, Darren Larsen 

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