Care Transitions

A care transition is a move from one healthcare setting, level of care, or healthcare team to another.

Common examples include:

• Moving from one hospital unit to another
• Moving from a hospital to another care setting
• Moving from a hospital to home
• Returning to the care of a primary care provider or specialist after a hospital stay

A move may mean a new team, different routines, or changes to your care plan. A clear transition helps your care continue and gives the next team the information it needs.

A handoff is when one care team passes important information and responsibility to the team taking over. Handoffs may happen during a shift change, a move to another unit or facility, or a hospital discharge.

Information shared during a handoff may include:

• Your diagnosis, recent symptoms, and current health concerns
• Your medications and known medication allergies
• Recent tests, results, and treatments
• Tests or treatments that are still planned
• Equipment or care needs, such as oxygen, drains, or wound care
• Safety needs, such as fall risk, mobility, or diet
• Follow-up appointments and instructions

Handoffs may include conversations between care professionals, information in your medical record, and written transfer or discharge instructions. You may not hear every part of the handoff, but you can ask what you need to know about your next steps.

During a handoff, the team taking over needs important information about your condition, medications, treatments, safety concerns, and next steps. You may be able to help by sharing concerns or asking what information has been passed along.

Responsibility for continuing your care moves to the receiving team, although responsibilities may overlap for a time during the transition.

“Does the next team have the information they need about my care?”

A clear handoff helps the next team continue your care.

Medication review is an important part of a care transition. During a hospital stay, medicines may be started, stopped, temporarily held, or changed.

Before moving to another care setting or going home, ask for an updated medication list. Make sure you understand:

• Which medicines to continue
• Which medicines to stop
• Which medicines are new
• Which medicines are temporarily held
• Whether any dose or schedule changed
• Why a medicine was added or changed

Medication reconciliation means comparing medication lists during a change in care to help identify differences and make sure the current list is accurate.

Before your transition, ask which medication list you should follow and whether any medicines you took before your hospital stay have changed.

Ask your healthcare team to explain any change you do not understand. Do not change or stop a prescribed medicine without checking with your healthcare professional.

A move to another hospital unit may happen when your care or monitoring needs change. Your new unit may have different routines and a different care team.

For example:

• ICU to step-down: You may need less intensive care but still need close monitoring.
• Step-down to a regular hospital unit: You may need less frequent monitoring.
• Emergency department to an inpatient unit: Your care continues in the hospital with a new team.

After a move, your monitoring and nursing care may change. For example, vital signs may be checked less often, or a nurse may care for more patients at a time.

Your previous team shares important information with the new team through a handoff and your medical record.

A transfer often reflects changing care needs. It does not always mean your recovery is complete.

Ask why the move is happening, what will change, and who will be caring for you in the new unit.

Some people need continued care after leaving the hospital. Depending on their needs, the next setting may be acute rehabilitation, a skilled nursing facility, long-term care, home health services, or another hospital or specialty center.

These settings provide different kinds of care. Ask your care team to explain which setting is being recommended for you and why.

Before the move, ask:

• What services or treatments will I receive there?
• What are the goals of my stay?
• Who will coordinate my care?
• What should I bring with me?
• How will my medications and care instructions be shared?
• Will my therapy plan, such as physical or occupational therapy, continue there?
• What is the expected care plan, and how long might I stay?

Available services, placement, insurance coverage, and transportation arrangements vary by situation. Ask your care team what has been arranged and what you may need to do.

Before going home, review your instructions with your care team. Make sure you know:

• Which medicines to take, and how to take them
• What symptoms or changes to watch for
• When and where your follow-up appointments will happen
• Whether you need additional tests
• Whether you need equipment or home health services
• Who to contact if you have a question or concern

• Pending Test Results“Are any test results still pending, and who will explain them to me?”
• Safe Home Care“Will I need assistance with walking, medications, equipment, daily activities, or other care at home?”
• When to Seek Help“What symptoms require a call to my healthcare team, and what symptoms require emergency assistance?”

Leaving the hospital does not always mean your recovery is complete. You may still need medications, follow-up appointments, rehabilitation, or support at home.

Ask for a written copy of your instructions. If something is unclear, ask your care team to explain it before you leave.

When you arrive at your next unit, facility, or home, check that you understand:

This checklist is for your own learning. It does not replace instructions or discharge planning from your healthcare team, and nothing you check is saved.

You can take part in your care transition by:

• Sharing your current medication list, allergies, and health concerns
• Asking what information is being passed to the next team
• Making sure you understand any medication changes
• Keeping your written instructions and contact numbers somewhere easy to find
• Bringing a family member, friend, or caregiver if you want help listening or taking notes
• Asking for an interpreter or other communication support if you need it

You do not need to remember every detail. Ask the team to repeat or explain anything that is unclear.

Before leaving, try explaining the important parts of your care plan in your own words. Your healthcare professional can clarify anything that was confusing.

“So I take my updated medications, attend my follow-up appointment, and call the number on my instructions if I have questions. Is that correct?”

This is called teach-back. It helps check whether information was communicated clearly — it is not a test of you.