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Wise Health Care Consumer: Take an Active Role During Transition of Care

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Everything You Need to Know About Transition of Care

Navigating healthcare can be stressful and complex, and in many cases, can result in an ineffective “transition of care” leading to hospital readmission. At a cost of over $26 billion per year, these readmissions impact health care resources, financial reserves and patients’ long-term health outcomes.

You can help improve these outcomes by proactively participating in your transition of care. February is National Wise Health Care Consumer Month, and we want to empower you to understand your health care options, ask questions and make educated decisions about your own health.

What is transition of care?

Transition of care refers to the movement of patients between healthcare practitioners and settings of care during treatment for a chronic or acute illness. Examples might include a patient who sees his/her personal doctor but also is evaluated by a specialist for a condition or illness, or a patient who needs to be hospitalized and is transferred from the hospital to a skilled nursing facility or back home.

There are potential barriers to an effective transition of care

• Poor communication between providers and facilities
• Incomplete transfer information
• Lack of education and/or understanding of care by the patient or caregiver
• Limited or poor essential service during recovery
• Absence of a single point person to ensure continuity of care

Ways to ensure a successful transition of care

Ask the facility or your insurance about access to a case manager

These are usually nurses or social workers who specialize in coordinating patient care. They can assist in navigating your transition. It is best to involve a case manager early in your care to discuss your options, so you and your family can make informed decisions about your care. Network Health offers care management services at no cost to many of our members. For more information, call 1-800-826-0940 or visit our website at

Have a family member or friend available when discussing your care and/or during your discharge

Many patients find it helpful to write their questions down ahead of time. It also helps to have another person available to help you remember details. Another person might also ask important questions that you haven’t thought to ask.

Request a written copy of all discharge instructions

Most facilities offer a written copy of your discharge instructions and recommended follow-up care. You might want to use this as a reference during your transition.

Set up follow-up appointments

Most facilities automatically set up follow-up appointments with the admitting provider. If not, ask the facility to arrange the follow-up visit. If the admitting provider is not your personal doctor, make sure your personal doctor receives a copy of the medical records from your illness/stay.

An effective transition of care empowers patients to make an informed healthcare decisions to maintain their health, independence and quality of life.

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