Improving transitions of care from hospital to home: what works?

As the cost of care rises and fragmentation of health care increases, care transitions have become critical parts of the health care system. Physicians and other inpatient providers have the responsibility to communicate to subsequent providers, but such communication occurs far less than is optimal. Timely discharge summaries for the next-level provider, postdischarge phone calls to patients, and postdischarge follow-up appointments with primary-care physicians or inpatient providers may improve postdischarge health care utilization. Pharmacists may also reduce medication errors, adverse medication events, and even readmissions. The most promising data, however, come from studies of multidisciplinary approaches, some of which have shown large reductions in postdischarge utilization and costs. More study is needed to pinpoint the most cost-effective and efficient strategies to improve transitions from the inpatient setting to other settings.