White Paper
March 1, 2009

March 2009

I. Introduction

Issues related to transitioning patients across sites of care increasingly have been in the national spotlight. There is evidence that poor transitions may result in adverse outcomes such as an avoidable re-hospitalization or medication errors.1 Problematic transitions often involve inadequate participation by a primary care provider (PCP). Nationally, the extent to which physicians follow their patients throughout the continuum of care varies considerably. It is hoped that programs such as the patient-centered medical home, now being evaluated by the Centers for Medicare & Medicaid Services (CMS), will encourage greater PCP involvement during the care transitions of their practice participants.

While much has been written about transitions between the acute and long-term care settings, there is minimal literature on transitions between the nursing home and the community-based setting. This paper focuses on the importance of patient-centered care in improving transitions from nursing facility to home- and community-based settings and proposes several solutions to addressing these issues. However, it is important to note that effective transitions out of the nursing facility begin with appropriate transitions into the nursing facility and good care during the stay. Otherwise, problems related to the patient and the information accompanying the patient can accumulate and adversely affect a successful transition elsewhere.