Navigating Health Care: Care Transitions - What You Need to Know
Rand: Whether you’re changing doctors, moving from a rehab facility to a nursing
home, or being discharged from a hospital, a transition in health care comes
with some risk. Patients - often those with complex medical needs - can face
potential problems, mostly resulting in miscommunications between health care
providers, clinicians, patients and their families. AHRQ Director Dr. Carolyn
Clancy is with us to talk about how to navigate these health care transitions.
Rand: Dr. Clancy, for consumers who may not be familiar with phrases like "care
transitions" or "medical handoffs" as some clinicians call them, what do these
Dr. Clancy: "Handoffs" is an informal term for a whole series of activities that
needs to take place when an individual transitions in care from one setting to
another, from one clinician to another. For example, this could happen when a
patient moves from one part of the hospital to another, when the patient is
discharged from the hospital, when a patient goes from a nursing home or rehab
facility home, or back to the hospital. All of these mean that the people taking
care of the patient are now changing, as the patient moves from one point to
another, and the information that the first group had, needs to move seamlessly
to the second group.
Rand: Well, it sounds like a pretty complicated process that we know is not
always well-coordinated. Why do patients need to pay particular attention during
a care transition or handoff?
Dr. Clancy: Handoffs can be pretty dangerous because health care is an
increasingly complex and fragmented process, and errors can occur when the
necessary systems aren’t in place or aren’t adhered to. So for example, one of
the most dangerous times for a patient is when there’s a transition between
doctors, and not all of the patient’s information follows. Another big risk at
any point of transition is medication error or lack of continuity of
Rand: Are any particular patients more vulnerable?
Dr. Clancy: Not surprisingly, older patients, over the age of 65, are
particularly affected and the reason for this is that the older you get, the
more likely it is that you have more hospitalizations with a greater severity of
illness. In addition to that, many older people aren’t able to return home
safely and may have to go from a hospital to a long-term care or short-term
rehabilitation facility. So that means the patient is moving across multiple
settings and that increases the opportunity for information not to be shared
Rand: It also seems like patients should be especially alert during their
transition out of the hospital, too.
Dr. Clancy: Well, the problem of handoffs or transitions can be even more acute
at discharge. For one thing, many patients are really, really excited to be
leaving the hospital, so anything that’s going to take more time they’re not
terribly interested in because they want to get out of there. Often times the
hospital personnel don’t have enough time to be able to educate the patient in a
way that’s clear and clear for them to understand. So many people enter the
discharge instructions conversation with an expectation that we can work this
out all later.
Rand: So what can patients do to help with handoffs and guard against problems
Dr. Clancy: First, carry a list with you, at all times, of all of your
medications, including over-the-counter, herbal supplements, vitamins, and so
forth, so if anything happens to you, or if you have an emergency, you don’t
have to rely on your memory you just always have the list with you. If you’re
asked something you don’t understand, ask that it be repeated in simple
language. If you’re given a new device to use, demonstrate how you think you’re
supposed to use it.
Rand: Dr. Clancy, what’s the bottom line here for consumers?
Dr. Clancy: For individuals who are able, the very best advice is, be active in
your own health care, which means you should take the initiative. Speak up.
Don’t worry about being polite. Ask clinicians to write down any information
that you’re going to need later.
Rand: For more great consumer tips, check out AHRQ’s Consumer and Patients Web
site at ahrq.gov/consumer.