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Transitions of Care

(Updated October 16th 2018)

Transitions of Care refers to care directed at making a smooth transition between levels of care and/or care settings. Several transition care programs and services have been developed and implemented in an effort to improve quality, reduce the cost of health care, and reduce hospital readmissions.

Patient-Centered Medical Homes conduct interventions such as post-hospital discharge follow-up phone calls within 24-48 hours and scheduling a return visit with the primary care physician within 5 to 7 days. The call ensures patients are contacted by someone they know and whom they have an established relationship.

Webinars and Presentations



Transition of Care Roles

Helps identify team members involved with transitions of care



LACE Index Scoring Tool for Risk Assessment of Hospital Readmission



IHI Transition of Care Resources