Improving Patient Safety: Care Transitions.

Care transitions are times of high risk of harm to patients. The transition from hospital care to outpatient care is perhaps the most well-studied transition and is encountered commonly in the family medicine setting. For discharge transitions, several hospital-based interventions for patients with major diagnoses have resulted in improvements in readmission rates, costs, and patient satisfaction. Prompt scheduling of a follow-up appointment with patients after discharge is crucial. Key issues to consider in the first post-discharge appointment include drug reconciliation and follow-up of any pending tests and results. In the outpatient setting, establishing working relationships with hospital physicians and consultants, educating patients to notify physicians of admissions to hospitals or other care facilities, and educating patients to bring current drug lists to appointments can improve care transitions. Physicians now can receive greater reimbursement for transitional care management services using new CPT codes.