Care transitions are defined as the movement patients make between different clinicians or settings—such as from a hospital to home or a nursing facility—during the course of their illness (see graphic below). These can be vulnerable times for patients and challenging to manage, especially for those with multiple chronic conditions.


Patients and their caregivers may be confused or overwhelmed, and may not understand what to expect, what medications to take, or how to address their needs during transitions. Poorly executed care transitions can lead to adverse events, unnecessary readmissions, reduced quality of life, and unneeded use of resources.

Transitional care encompasses a range of services designed to ensure continuity and promote safe and coordinated transitions between settings and clinicians.

PCORI’s multi-stakeholder Advisory Panel on Improving Healthcare Systems has identified improving transitional care as a priority research topic because of its potential to improve patient outcomes.

Transitional care is universal. It doesn't matter whether you have a brain injury, or had a hip replacement, a stroke, or a spinal-cord injury...a smooth transition is really important for reducing the number of re-hospitalizations.

Minna Hong Patient Partner, Peer Support Manager, Shepherd Center

To date, PCORI has invested $132.5 million in 30 projects across 16 states and Washington, DC, to study transitional care interventions. Studies target a range of diseases (e.g., stroke, traumatic injury) and populations (e.g., Medicare beneficiaries, rural residents, patients of low socioeconomic status). These projects compare different approaches to transitional care to determine which work best for which patients, given their needs, circumstances, and preferences, so they and those who care for them can make better-informed decisions.

Learn more about how PCORI-funded researchers are partnering with patients and other stakeholders to improve care transitions for specific populations in this PCORI feature article.

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