Closing the transition gaps the changing context of home healthcare coordination.

Legislative enactment of the Patient Protection and Affordable Care Act in 2010 created an impetus for change within the healthcare industry. As a result, the entire healthcare continuum is under greater scrutiny and incentives for performance levels and subsequent outcomes. Home healthcare clinicians have a vital role in the emerging spotlight of care transitions from hospital to home. Home healthcare clinicians will need to understand the concepts of patient engagement and patient activation, and have tactical plans for success. Understanding best practices and recommendations will be an element of competitive differentiation. This article reviews these concepts, along with interventions to target health literacy, communication with patients and families, and the use of motivational interviewing.