Better coordination of patient transfers among care sites, clinical workers and the community could save money and improve the quality of care.

The term care transition describes a continuous process in which a patient’s care shifts from being provided in one setting of care to another, such as from a hospital to a patient’s home or to a skilled nursing facility and sometimes back to the hospital.

Poorly managed transitions can diminish health and increase costs. Researchers have estimated that inadequate care coordination, including inadequate management of care transitions, was responsible for $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions.

For years, health policy experts have identified poor care transitions as a major contributor to poor quality and waste.

–Health Affairs Health Policy Brief, 2012.