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Change is Inevitable, not Inevitably Uncomfortable

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Understanding Transition of Care

Knowledge is power.

February is National Wise Healthcare Consumer Month. Observe it by increasing your knowledge of the healthcare options to advance your health.

This knowledge is especially important when you’re facing an unexpected hospitalization or moving from one level of care to another. This process of change is called a “transition of care,” and it can be confusing, frightening and overwhelming. Confusion with your transition of care could result in complications and unnecessary hospital readmissions, so understanding how to navigate this process is incredibly important. 

What is transition of care?

Medicare defines transition of care as “the movement of a patient from one setting of care to another.” When a patient transitions from one level of care, such as an inpatient hospital stay, to another level of care, such as returning to their home, this is a transition of care.

During a transition of care, the patients most at risk for complications are elderly and populations with multiple health problems and few or no support systems.

There are many pitfalls during this stressful time. The most frequent barriers to a smooth transition of care include the following.

  • Poor communication
  • Incomplete transfer of information
  • Inadequate education of older adults and their family caregivers
  • Limited access to essential services
  • Absence of a single point of contact to ensure continuity of care

Families and/or significant others play the most important roles in supporting older adults during a transition of care. If you have reliable friends and/or family, their involvement in your healthcare is vital.

How to ensure a smooth transition of care

There are simple, common-sense steps that you can take to facilitate a safe and effective transition of care.

1. Have a centralized medical professional to coordinate your transition of care

Many hospitals and health plans have designated care managers who are specialists in community resources and healthcare.

The care manager functions as a central point of contact and coordination of care to promote continuity and effectiveness of your care to meet your individualized needs.

Network Health has a highly skilled and knowledgeable care management team that members may utilize at no cost. Our care managers can assist you and your family in successfully navigating a transition of care while preserving independence. For more information, call 1-800-826-0940 or visit

2. Spread the knowledge to those who can help

Have a family member or friend attend any discussions regarding your care and discharge planning. They may be able to assist you in addressing some of your needs or ask questions you don’t think of. If you do have questions, write them down ahead of time so you don’t forget to ask them.

3. Ask that all discharge instructions be provided in writing

Many patients find the amount of information provided at discharge overwhelming. Having a written copy of the information allows you to review the information at your convenience and ensure you understand it.

4. Ask your care manager to set up all follow-up appointments before you are discharged

Making follow-up appointments can be easy to forget. Having your care manager do this will help ensure you receive the follow-up care you need.

If your care is being provided by a doctor other than your personal doctor, request a copy of your medical records (including the hospital records) to be forwarded to your personal doctor for review. This will allow your personal doctor to assess if your condition has been resolved or requires further assessment and/or treatment.

Being a wise healthcare consumer includes collecting all the information you need to make an informed decision about your health.

Network Health has a wealth of knowledge available through our team of healthcare transition professionals. If you have any questions, feel free to contact Network Health by calling 1-800-826-0940 or sending an email to

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