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Journal articles on the topic 'Transitions of Care'

Author: Grafiati

Published: 4 June 2021

Last updated: 30 January 2023

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1

de Boer, Bram, Hilde Verbeek, and Joseph Gaugler. "Transitions to Long-Term Residential Care Settings." Innovation in Aging 5, Supplement_1 (December 1, 2021): 221–22. http://dx.doi.org/10.1093/geroni/igab046.855.

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Abstract During their life course, many older adults encounter a transition between care settings, for example, a permanent move into long-term residential care. This care transition is a complex and often fragmented process, which is associated with an increased risk of negative health outcomes, rehospitalisation, and even mortality. Therefore, care transitions should be avoided where possible and the process for necessary transitions should be optimised to ensure continuity of care. Transitional care is therefore a key research topic. The TRANS-SENIOR European Joint Doctorate (EJD) network builds capacity for tackling a major challenge facing European long-term care systems: the need to improve care for an increasing number of care-dependent older adults by avoiding unnecessary transitions and optimising necessary care transitions. During this symposium, four presenters from the Netherlands and Switzerland will present different aspects of transitions into long-term residential care. The first speaker presents the results of a co-creation approach in developing an intervention aimed at preventing unnecessary care transitions. The second speaker presents an overview of interventions aiming to improve a transition from home to a nursing home, highlighting the clear mismatch between theory and practice. The third speaker presents the impact of the COVID-19 pandemic on transitions into long-term residential care using an ethnographic study in a long-term residential care facility in Switzerland. The final speaker discusses the results of a recent Delphi study on key factors influencing implementing innovations in transitional care. The discussant will relate previous findings on transitional care with a U.S. perspective.

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Shin, Ji Youn, Nkiru Okammor, Karly Hendee, Amber Pawlikowski, Grace Jenq, and David Bozaan. "Development of the Socioeconomic Screening, Active Engagement, Follow-up, Education, Discharge Readiness, and Consistency (SAFEDC) Model for Improving Transitions of Care: Participatory Design." JMIR Formative Research 6, no. 4 (April 12, 2022): e31277. http://dx.doi.org/10.2196/31277.

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Background Transition to home after hospitalization involves the potential risk of adverse patient events, such as knowledge deficits related to self-care, medication errors, and readmissions. Despite broad organizational efforts to provide better care transitions for patients, there are challenges in implementing interventions that effectively improve care transition outcomes, as evidenced by readmission rates. Collaborative efforts that require health care professionals, patients, and caregivers to work together are necessary to identify gaps associated with transitions of care and generate effective transitional care interventions. Objective This study aims to understand the usefulness of participatory design approaches in identifying the design implications of transition of care interventions in health care settings. Through a series of participatory design workshops, we have brought stakeholders of the health care system together. With a shared understanding of care transition and patient experience, we have provided participants with opportunities to generate possible design implications for care transitions. Methods We selected field observations in clinical settings and participatory design workshops to develop transitional care interventions that serve each hospital’s unique situation and context. Patient journey maps were created and functioned as tools for creating a shared understanding of the discharge process across different stakeholders in the health care environment. The intervention sustainability was also assessed. By applying thematic analysis methods, we analyzed the problem statements and proposed interventions collected from participatory design workshops. The findings showed patterns of major discussion during the workshop. Results On the basis of the workshop results, we formalized the transition of care model—the socioeconomic, active engagement, follow-up, education, discharge readiness tool, and consistency (Integrated Michigan Patient-centered Alliance in Care Transitions transition of care model)—which other organizations can apply to improve patient experiences in care transition. This model highlights the most significant themes that should necessarily be considered to improve the transition of care. Conclusions Our study presents the benefits of the participatory design approach in defining the challenges associated with transitions of care related to patient discharge and generating sustainable interventions to improve care transitions.

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Taylor, Genevieve, Melissa Smith, Sarah Dotters-Katz, Arlene Davis, Wayne Price, and Jacquelyn Patterson. "Transitions in Care for Infants with Trisomy 13 or 18." American Journal of Perinatology 34, no. 09 (March 16, 2017): 887–94. http://dx.doi.org/10.1055/s-0037-1600912.

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Background and Objectives The scope of interventions offered to infants with trisomy 13 (T13) or trisomy 18 (T18) is increasing. We describe the spectrum of care provided, highlighting transitions in care for individual patients. Patients and Methods This is a single-center, retrospective cohort of infants with T13 or T18 born between 2004 and 2015. Initial care was classified as comfort care or intervention using prenatal counseling notes. Transitions in care were identified in the medical record. Results In this study, 25 infants were divided into two groups based on their care: neonates who experienced no transition in care and neonates who experienced at least one transition. Eleven neonates experienced no transition in care with 10 receiving comfort care. Fourteen neonates experienced at least one transition: three transitioned from comfort care to intervention and 11 from intervention to comfort care. The three initially provided comfort care were discharged home with hospice and readmitted. Among the 11 cases who transitioned from intervention to comfort care, 9 transitioned during the birth hospitalization, 6 had no prenatal suspicion for T13 or T18, and 5 experienced elective withdrawal of intensive care. Conclusion The spectrum of care for infants with T13 or T18 illustrates the need for individualized counseling that is on-going, goal directed, collaborative, and responsive.

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Harvey, Desley, Michele Foster, Rachel Quigley, and Edward Strivens. "Care transition types across acute, sub-acute and primary care." Journal of Integrated Care 26, no. 3 (July 2, 2018): 189–98. http://dx.doi.org/10.1108/jica-12-2017-0047.

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PurposeThe purpose of the paper is to examine the care transitions of older people who transfer between home, acute and sub-acute care to determine if there were common transition types and areas for improvements.Design/methodology/approachA longitudinal case study design was used to examine care transitions of 19 older people and their carers as a series of transitions and a whole-of-system experience. Case study accounts synthesising semi-structured interviews with function and service use data from medical records were compared.FindingsThree types of care transitions were derived from the analysis: manageable, unstable and disrupted. Each type had distinguishing characteristics and older people could experience elements of all types across the system. Transition types varied according to personal and systemic factors.Originality/valueThis study identifies types of care transition experiences across acute, sub-acute and primary care from the perspective of older people and their carers. Understanding transition types and their features can assist health professionals to better target strategies within and across the system and improve patient experiences as a whole.

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Smith, Audris D., and Judith Treschuk. "Disconnects and Silos in Transitional Care: Single-Case Study of Model Implementation in Home Health Care." Home Health Care Management & Practice 30, no. 3 (March 22, 2018): 130–39. http://dx.doi.org/10.1177/1084822318765737.

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Transitional care incorporates actions to ensure the coordination and continuity of care between provider settings (ie, hospitals, nursing homes, home health care, patients’ home, and physician offices) occurs to meet the patient’s goals relative to their disease management. The evolution of transitional care over the past decade has facilitated the emergence of several transitional care models. However, there is a dearth of understanding related to the collaboration between nurse transition coaches and home care nurses when implementing transitional care model activities to achieve desired patient outcomes in the home health care setting. This case study describes the enactment of a specific transitional care model’s conceptual framework to derive an in-depth understanding of the collaborations between nurse transition coaches and home health nurses in the unique context of home health care. The case is a specific patient-centered Care Transitions Intervention (CTI) model with 4 embedded subunits: (1) the experiences and actions of the nurse transitions coach, (2) the experiences and actions of the home health nurse, (3) document and artifacts review, and (4) the experiences and observations of key leadership stakeholders involved in transitional care activities in one home health care organization located in Michigan.

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Sheikh, Fatima, Evelyn Gathecha, Alicia I. Arbaje, and Colleen Christmas. "Internal Medicine Residents’ Views About Care Transitions: Results of an Educational Intervention." Journal of Medical Education and Curricular Development 8 (January 2021): 238212052098859. http://dx.doi.org/10.1177/2382120520988590.

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Problem: Suboptimal care transitions can lead to re-hospitalizations. Intervention: We developed a 2-week “Transitions of Care Curriculum” to train first-year internal medicine residents to improve their knowledge and skills to deliver optimal transitional care. Our objective was to use reflective writing essays to evaluate the impact of the curriculum on the residents. Methods: The rotation included: Transition of Care Teaching modules, Transition Audit, Transitional Care Site Visits, and Transition of Care Conference. Residents performed the above elements of care transitions during the curriculum and wrote reflective essays about their experiences. These essays were analyzed to assess for the overall impact of the curriculum on the residents. Qualitative analysis of reflective essays was used to evaluate the impact of the curriculum. Of the 20 residents who completed the rotation, 18 reflective essays were available for qualitative analysis. Results: Five major themes identified in the reflective essays for improvement were: discharge planning, patient-centered care, continuity of care, goals of care discussions, and patient safety. The most discussed theme was continuity of care, with following subthemes: fragmentation of the healthcare system, disjointed care to the patients, patient specific factors contributing to lack of continuity of care, lack of primary care provider role as a coordinator of care, and challenges during discharge process. Residents also identified system-based gaps and suggested solutions to overcome these gaps. Conclusions: This experiential learning and use of reflective writing enhanced the residents’ self-identified awareness of gaps in care transitions and prompted them to generate ideas for systems improvement and personal actions to improve their practice during care transitions.

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DUCKETT, KATHY. "Care Transitions." Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional 29, no. 10 (November 2011): 590–91. http://dx.doi.org/10.1097/nhh.0b013e3182373069.

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Dusek, Brenda, Nancy Pearce, Anastasia Harripaul, and Monique Lloyd. "Care Transitions." Journal of Nursing Care Quality 30, no. 3 (2015): 233–39. http://dx.doi.org/10.1097/ncq.0000000000000097.

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Dreyer, Theresa. "Care Transitions." Home Healthcare Nurse 32, no. 5 (May 2014): 309–16. http://dx.doi.org/10.1097/nhh.0000000000000069.

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10

Geary, Carol R., and Karen L. Schumacher. "Care Transitions." Advances in Nursing Science 35, no. 3 (2012): 236–48. http://dx.doi.org/10.1097/ans.0b013e31826260a5.

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Thorley, N., M. Chakravorty, R. Schiff, E. Oikonomou, R. Symes, E. Seymour, and C. Vincent. "1 Quality of Care Transitions: Older Adults’ Experiences in An Integrated Care Trust." Age and Ageing 50, Supplement_1 (March 2021): i1—i6. http://dx.doi.org/10.1093/ageing/afab028.01.

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Abstract Introduction The transition of care from hospital to home is a high-risk time for older adults. The Partners at Care Transitions (PACT) programme aims to improve safety and quality of care transitions. We aimed to test the feasibility of using the Partners at Care Transitions Measure (PACT-M) to evaluate older adults’ experiences of the transition from hospital to home in an Inner London Integrated Care Trust and to identify factors impacting transition quality. Methods The PACT-M, a validated patient-reported questionnaire designed to evaluate care transitions, was administered to patients ≥65 years at 7, 30 and 90 days post-discharge. Likert scores were analysed quantitatively and manual thematic analysis performed on free-text comments. Results 101 participants were recruited. Mean age 77.8 years. 84, 70 and 65 participants completed follow-up at 7, 30 and 90 days, respectively. Factors impacting patients’ experience of transition quality are shown in Table 1. Conclusions

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Bouldin, Erin, Benjamin Brintz, Jared Hansen, Randall Rupper, Rachel Brenner, Orna Intrator, Bruce Kinosian, and Mary Jo Pugh. "GERIATRIC AND EXTENDED CARE TRAJECTORIES AND TRANSITIONS AMONG VETERANS WITH LONG-TERM CARE NEEDS." Innovation in Aging 6, Supplement_1 (November 1, 2022): 45–46. http://dx.doi.org/10.1093/geroni/igac059.174.

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Abstract We aimed to identify clusters of geriatric and extended care services used by Veterans, describe transitions between clusters, and identify factors influencing transition. We explored services across the continuum of care from clinic to home-based and institutional care services. Analyses include 104,837 Veterans Health Administration (VHA) patients 65 years and older, and used VHA and Centers for Medicare & Medicaid Services (CMS) data from FY15-FY17. Using latent class and latent transition analyses, we identified 5 latent classes: 1) No Services, 2) CMS Services, 3) Home-Centered Interdisciplinary Care, 4) Personal Care Services, and 5) VHA-CMS Care Continuum. Veterans most commonly transitioned from the CMS Care Continuum class to No Services. Veterans also frequently transitioned into the VHA-CMS Care Continuum class over time. Identifying service patterns can inform service delivery, program development, and future resource allocation to better meet aging Veterans’ needs.

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Berish, Diane E., Robert Applebaum, and Jane K. Straker. "The Residential Long-Term Care Role in Health Care Transitions." Journal of Applied Gerontology 37, no. 12 (November 11, 2016): 1472–89. http://dx.doi.org/10.1177/0733464816677188.

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The objective of the current study is to describe the activities long-term care facilities are undertaking to reduce hospital admissions and readmissions by working to improve health care transitions. The data were collected via an online survey from 888 nursing facilities (NFs) and 527 residential care facilities (RCFs) that completed the care integration module of the Ohio Biennial Survey of Long-Term Care. Questions focused on partnerships, current work, type of care model, and perceived barriers to reducing hospital readmissions. More than nine in 10 (93.1%) of NFs and 63.6% of RCFs reported being engaged in a program to reduce hospital admissions/readmissions. Evidence-based care models were utilized by two thirds of NFs and one third of RCFs. Financial barriers were the most frequently cited challenges faced by facilities. Long-term care settings are increasingly becoming transitional care stops for short-term stay residents. Ensuring that facilities are well versed in current transition research and practice is critical to improve system outcomes.

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Saunders, Stephanie, Marianne E. Weiss, Chris Meaney, Tieghan Killackey, Jaymie Varenbut, Emily Lovrics, Natalie Ernecoff, et al. "Examining the course of transitions from hospital to home-based palliative care: A mixed methods study." Palliative Medicine 35, no. 8 (September 2021): 1590–601. http://dx.doi.org/10.1177/02692163211023682.

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Background: Hospital-to-home transitions in palliative care are fraught with challenges. To assess transitions researchers have used patient reported outcome measures and qualitative data to give unique insights into a phenomenon. Few measures examine care setting transitions in palliative care, yet domains identified in other populations are likely relevant for patients receiving palliative care. Aim: Gain insight into how patients experience three domains, discharge readiness, transition quality, and discharge-coping, during hospital-to-home transitions. Design: Longitudinal, convergent parallel mixed methods study design with two data collection visits: in-hospital before and 3–4 weeks after discharge. Participants completed scales assessing discharge readiness, transition quality, and post discharge-coping. A qualitative interview was conducted at both visits. Data were analyzed separately and integrated using a merged transformative methodology, allowing us to compare and contrast the data. Setting and participants: Study was set in two tertiary hospitals in Toronto, Canada. Adult inpatients ( n = 25) and their caregivers ( n = 14) were eligible if they received a palliative care consultation and transitioned to home-based palliative care. Results: Results were organized aligning with the scales; finding low discharge readiness (5.8; IQR: 1.9), moderate transition quality (66.7; IQR: 33.33), and poor discharge-coping (5.0; IQR: 2.6), respectively. Positive transitions involved feeling well supported, managing medications, feeling well, and having healthcare needs met. Challenges in transitions were feeling unwell, confusion over medications, unclear healthcare responsibilities, and emotional distress. Conclusions: We identified aspects of these three domains that may be targeted to improve transitions through intervention development. Identified discrepancies between the data types should be considered for future research exploration.

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Baxter, Ruth, Jane O’Hara, Jenni Murray, Laura Sheard, Alison Cracknell, Robbie Foy, John Wright, and Rebecca Lawton. "Partners at Care Transitions: exploring healthcare professionals’ perspectives of excellence at care transitions for older people." BMJ Open 8, no. 9 (September 2018): e022468. http://dx.doi.org/10.1136/bmjopen-2018-022468.

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IntroductionHospital admissions are shorter than they were 10 years ago. Notwithstanding the benefits of this, patients often leave hospital requiring ongoing care. The transition period can therefore be risky, particularly for older people with complex health and social care needs. Previous research has predominantly focused on the errors and harms that occur during transitions of care. In contrast, this study adopts an asset-based approach to learn from factors that facilitate safe outcomes. It seeks to explore how staff within high-performing (‘positively deviant’) teams successfully support transitions from hospital to home for older people.Methods and analysisSix high-performing general practices and six hospital specialties that demonstrate exceptionally low or reducing 30-day emergency hospital readmission rates will be invited to participate in the study. Healthcare staff from these clinical teams will be recruited to take part in focus groups, individual interviews and/or observations of staff meetings. Data collection will explore the ways in which teams successfully deliver exceptionally safe transitional care and how they overcome the challenges faced in their everyday clinical work. Data will be thematically analysed using a pen portrait approach to identify the manifest (explicit) and latent (abstract) factors that facilitate success.Ethics and disseminationEthical approval was obtained from the University of Leeds. The study will help develop our understanding of how multidisciplinary staff within different healthcare settings successfully support care transitions for older people. Findings will be disseminated to academic and clinical audiences through peer-reviewed articles, conferences and workshops. Findings will also inform the development of an intervention to improve the safety and experience of older people during transitions from hospital to home.

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Kim, Christopher S., and Scott A. Flanders. "Transitions of Care." Annals of Internal Medicine 158, no. 5_Part_1 (March 5, 2013): ITC3. http://dx.doi.org/10.7326/0003-4819-158-5-201303050-01003.

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Welch, Shelly R., Ann K. Carruth, Ralph Wood, Bobijo Bode, Amy Babineaux-Jones, Cortney Mitchell, Gina Burdett, Brandy Davis, and Charles Ducombs. "Improving Care Transitions." JONA: The Journal of Nursing Administration 48, no. 12 (December 2018): 629–35. http://dx.doi.org/10.1097/nna.0000000000000696.

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Roberts, Leah, and Benjamin A. Bensadon. "Transitions of care." Medical Teacher 42, no. 1 (April 18, 2019): 116–17. http://dx.doi.org/10.1080/0142159x.2019.1605162.

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Hilligoss, Brian, and Timothy J. Vogus. "Navigating Care Transitions." Medical Care Research and Review 72, no. 1 (December 16, 2014): 25–48. http://dx.doi.org/10.1177/1077558714563170.

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PHD, ELIZABETH TANNER. "Transitions of Care." Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional 28, no. 2 (February 2010): 61–62. http://dx.doi.org/10.1097/nhh.0b013e3181cda158.

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Delisle, Dennis R. "Care Transitions Programs." Professional Case Management 18, no. 6 (2013): 273–83. http://dx.doi.org/10.1097/ncm.0b013e31829d9cf3.

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Canada, Kelli E., Colleen Galambos, Angelita Pritchett, Laura Rollin, Lori L. Popejoy, Amy Vogelsmeier, and Marilyn Rantz. "Transitions of Care." Journal of Nursing Care Quality 35, no. 3 (2020): 189–94. http://dx.doi.org/10.1097/ncq.0000000000000478.

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Propp, D. A. "Emergency Care Transitions." Academic Emergency Medicine 10, no. 10 (October 1, 2003): 1143. http://dx.doi.org/10.1197/s1069-6563(03)00385-3.

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Rasmusson, Kismet. "Transitions in care." Heart & Lung 39, no. 1 (January 2010): 1. http://dx.doi.org/10.1016/j.hrtlng.2009.11.001.

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&NA;. "Care Transitions Programs." Professional Case Management 18, no. 6 (2013): 284–85. http://dx.doi.org/10.1097/ncm.0000000000000001.

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Howard, Elisabeth D. "Transitions in Care." Journal of Perinatal & Neonatal Nursing 32, no. 1 (2018): 7–11. http://dx.doi.org/10.1097/jpn.0000000000000301.

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Lee, Jennifer I., Fran Ganz-Lord, Judy Tung, Tara Bishop, Carol DeJesus, Claire Ocampo, Paula Tinghitella, and Karen A. Scott. "Bridging Care Transitions." Academic Medicine 88, no. 11 (November 2013): 1685–88. http://dx.doi.org/10.1097/acm.0b013e3182a7cd55.

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Klein, Jared W. "Transitions in Care." Journal of General Internal Medicine 26, no. 5 (December 21, 2010): 566. http://dx.doi.org/10.1007/s11606-010-1602-8.

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Lumb, Philip D. "Critical care transitions." Journal of Critical Care 30, no. 3 (June 2015): 443. http://dx.doi.org/10.1016/j.jcrc.2015.03.020.

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Foster, Michele, Desley Harvey, Rachel Quigley, and Edward Strivens. "Care transitions as street-level work." Journal of Integrated Care 25, no. 3 (July 3, 2017): 196–207. http://dx.doi.org/10.1108/jica-11-2016-0044.

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Purpose Quality care transitions of older people across acute, sub-acute and primary care are critical to safety and cost, which is the reason interventions to improve practice are a priority. Yet, given the complexity of providers and services involved it is often difficult to know the types of tensions that arise in day-to-day transition work or how front-line workers will respond. To that end, this innovative study differs from the largely descriptive studies by conceptualising care transitions as street-level work in order to capture how transition practice takes shape within the complexities and dynamics of the local setting. The paper aims to discuss these issues. Design/methodology/approach Data were collected from 23 hospital health professionals and community service providers across primary, sub-acute and acute care through focus groups. A thematic analysis and interrogation of themes using street-level concepts derived three key themes. Findings The themes of risk logics and dilemmas of fragmentation make explicit both the local constraints and opportunities of care transitions and how these intersect to engender a particular logic of practice. By revealing the various discretionary tactics adopted by front-line providers, the third theme simultaneously highlights how discretionary spaces might represent both possibilities and problematics for balancing organisational and patient needs. Originality/value The study contributes to the knowledge of street-level work in health settings and specifically, the nature of transition work. Importantly, it benefits policy and practice by uncovering mechanisms that could facilitate and impede quality transitions in discrete settings.

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Killackey, Tieghan, Emily Lovrics, Stephanie Saunders, and Sarina R. Isenberg. "Palliative care transitions from acute care to community-based care: A qualitative systematic review of the experiences and perspectives of health care providers." Palliative Medicine 34, no. 10 (August 8, 2020): 1316–31. http://dx.doi.org/10.1177/0269216320947601.

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Background: Transitioning from the hospital to community is a vulnerable point in patients’ care trajectory, yet little is known about this experience within the context of palliative care. While some studies have examined the patient and caregiver experience, no study to date has synthesized the literature on the healthcare provider’s perspective on their role and experience facilitating these transitions. Aim: The purpose of this systematic review was to understand the experience and perspective of healthcare providers who support the transition of patients receiving palliative care as they move from acute care to community settings. Design: A qualitative systematic review of studies using thematic analysis as outlined by Thomas and Harden. PROSPERO: ID # CRD42018109662. Data Sources: We searched four databases: MEDLINE, Embase, ProQuest and CINAHL for studies published in English from 1995 until May 22, 2020. Four reviewers screened records using the following selection criteria: (1) peer-reviewed empirical study, (2) adult sample, (3) qualitative study design, (4) perspective of healthcare providers, and (5) included a component of transitions between acute to community-based palliative care. Study findings were analyzed using thematic analysis which entailed: (1) grouping the findings into recurring themes; (2) iteratively referring back to the articles to obtain nuances of the theme and quotations; and (3) defining and solidifying the themes. Results: Overall 1,791 studies were identified and 15 met inclusion criteria. Studies were published recently (>2015, n = 12, 80%) and used a range of qualitative methods including semi-structured interviews, focus groups, and field interviews. Three core themes related to the role and experience of healthcare providers were identified: (1) assessing and preparing for transition; (2) organizing and facilitating the logistics of transition; and (3) coordinating and collaborating transitional care across sectors. The majority of studies focused on the discharge process from acute care; there was a lack of studies exploring the experiences of healthcare providers in the community who receive patients from acute care and provide them with palliative care at home. Conclusion: This review identified studies from a range of relatively high-income countries that included a diverse sample of healthcare providers. The results indicate that healthcare providers experience multiple complex roles during the transition facilitation process, and future research should examine how to better assist clinicians in supporting these transitions within the context of palliative care provision.

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Saleem, Jason J., and Jennifer Herout. "Transitioning from one Electronic Health Record (EHR) to Another: A Narrative Literature Review." Proceedings of the Human Factors and Ergonomics Society Annual Meeting 62, no. 1 (September 2018): 489–93. http://dx.doi.org/10.1177/1541931218621112.

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This paper reports the results of a literature review of health care organizations that have transitioned from one electronic health record (EHR) to another. Ten different EHR to EHR transitions are documented in the academic literature. In eight of the 10 transitions, the health care organization transitioned to Epic, a commercial EHR which is dominating the market for large and medium hospitals and health care systems. The focus of the articles reviewed falls into two main categories: (1) data migration from the old to new EHR and (2) implementation of the new EHR as it relates to patient safety, provider satisfaction, and other measures pre-and post-transition. Several conclusions and recommendations are derived from this review of the literature, which may be informative for healthcare organizations preparing to replace an existing EHR. These recommendations are likely broadly relevant to EHR to EHR transitions, regardless of the new EHR vendor.

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Malebranche, Mary, Apostolos Sarivalasis, Solange Peters, Patrice Mathevet, Jacques Cornuz, and Patrick Bodenmann. "Primary Care-Led Transition Clinics Hold Promise in Improving Care Transitions for Cancer Patients Facing Social Disparities: A Commentary." Journal of Primary Care & Community Health 11 (January 2020): 215013272095745. http://dx.doi.org/10.1177/2150132720957455.

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Transitions in care are key junctions during which care coordination, communication, and individualized support are required to ensure optimal health outcomes for patients. This is particularly true for patients who face social disparities, such as poverty, limited health literacy, or belonging to a racial or ethnic minority, who are particularly at risk for experiencing poor care transitions. Interdisciplinary primary care-led transition clinics are an intervention that have shown promise in improving care transitions for diverse patient populations, including those that face social disparities, but their role in improving transitions in cancer care remains largely untapped. In this commentary we highlight why the time-limited support of an interdisciplinary primary care-led transition clinic that targets socially vulnerable cancer patients holds the promise of achieving more equitable healthcare access, healthcare quality, and ultimately more equitable health outcomes for cancer patients.

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Velligan, Dawn I., David Roberts, Melissa Martinez, Megan Fredrick, Kiley Hillner, and Philip Luber. "Following AACP Guidelines for Transitions in Care: The Transitional Care Clinic." Psychiatric Services 67, no. 3 (March 2016): 259–61. http://dx.doi.org/10.1176/appi.ps.201500435.

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Flink, Maria, Mesfin Tessma, Milada Cvancarova Småstuen, Marléne Lindblad, Eric A. Coleman, and Mirjam Ekstedt. "Measuring care transitions in Sweden: validation of the care transitions measure." International Journal for Quality in Health Care 30, no. 4 (February 8, 2018): 291–97. http://dx.doi.org/10.1093/intqhc/mzy001.

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Choi, Youngjee. "Care Coordination and Transitions of Care." Medical Clinics of North America 101, no. 6 (November 2017): 1041–51. http://dx.doi.org/10.1016/j.mcna.2017.06.001.

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Boling, Peter A. "Care Transitions and Home Health Care." Clinics in Geriatric Medicine 25, no. 1 (February 2009): 135–48. http://dx.doi.org/10.1016/j.cger.2008.11.005.

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Reynolds, J. D., N. B. Goodwin, and R. P. Freckleton. "Evolutionary transitions in parental care and live bearing in vertebrates." Philosophical Transactions of the Royal Society of London. Series B: Biological Sciences 357, no. 1419 (March 29, 2002): 269–81. http://dx.doi.org/10.1098/rstb.2001.0930.

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We provide the first review of phylogenetic transitions in parental care and live bearing for a wide variety of vertebrates. This includes new analyses of both numbers of transitions and transition probabilities. These reveal numerous transitions by shorebirds and anurans toward uniparental care by either sex. Whereas most or all of the shorebird transitions were from biparental care, nearly all of the anuran transitions have been from no care, reflecting the prevalence of each form of care in basal lineages in each group. Teleost (bony) fishes are similar to anurans in displaying numerous transitions toward uniparental contributions by each sex. Whereas cichlid fishes have often evolved from biparental care to female care, other teleosts have usually switched from no care to male care. Taxa that have evolved exclusive male care without courtship–role reversal are characterized by male territoriality and low costs of care per brood. Males may therefore benefit from care through female preference of parental ability in these species. Primates show a high frequency of transitions from female care to biparental care, reflecting the prevalence of female care in basal lineages. In the numerous taxa that display live bearing by females, including teleosts, elasmobranchs, squamate reptiles and invertebrates, we find that live bearing has always evolved from a lack of care. Although the transition counts and probabilities will undoubtedly be refined as phylogenetic information and methodologies improve, the overall biases in these taxa should help to place adaptive hypotheses for the evolution of care into a stronger setting for understanding directions of change.

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Shirley, Benjamin, Nathaniel Erskine, David D. McManus, Catarina I. Kiefe, Milena Anatchkova, and Heena P. Santry. "Who’s in charge? Results from a qualitative study of caregiver perspectives on the care transition process." European Journal for Person Centered Healthcare 6, no. 1 (April 30, 2018): 50. http://dx.doi.org/10.5750/ejpch.v6i1.1399.

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Background: Care transitions are a topic of increasing interest as researchers and clinicians focus their effects on patient outcomes. Engaging caregivers, who play important roles in care transitions, may yield valuable insight into how care transition processes can be improved. Methods: We conducted semi-structured interviews, focusing on caregivers’ experiences with and perceptions of care transitions, with 11 eligible caregivers whose loved ones had recently experienced an unplanned admission to a single academic medical center. Our research team analyzed the transcripts to identify key themes.Results: Caregivers detailed multiple factors affecting care transitions, including both in-hospital and external elements. Identifying the medical provider in charge of care emerged as a common difficulty. Other areas of interest included receiving discharge information, length of stay, health insurance status, the presence of social support, access to transportation and educational level, among others. Caregivers’ views on the quality of various in-hospital aspects of their own care transition experiences varied.Conclusions: Caregivers re-affirmed the complexity of the care transition process by identifying myriad factors that influence their quality. Taking steps to address these factors may help hospitals to empower and engage caregivers, as well as to improve care transitions overall and better manage the health of their patients.

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Nguyen, Annie L., Tingjian Yan, Kathleen Ell, Jorge Gonzalez, and Susan Enguidanos. "Care transitions among Latino diabetics: barriers to study enrollment and transition care." Ethnicity & Health 22, no. 4 (October 21, 2016): 361–71. http://dx.doi.org/10.1080/13557858.2016.1244626.

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McIntosh, Jennifer. "Therapeutic transitions in out of home care." Children Australia 24, no. 4 (1999): 29–33. http://dx.doi.org/10.1017/s1035077200009342.

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This paper sets out a series of principles for minimising the trauma of transitions experienced by children in out of home care. It is based on a child centred approach that has as its goal making transition bearable and psychologically useful for each child who must go through it, creating a space where even previous transition wounds might heal. The paper concentrates particularly on the complexities of helping children to move between foster care and permanent care placements.

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Ricketts, Thomas C. "Policy Forum: Care Transitions." North Carolina Medical Journal 73, no. 1 (January 2012): 29–30. http://dx.doi.org/10.18043/ncm.73.1.29.

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Wanderer, Jonathan P., and James P. Rathmell. "Care Transitions: Handover Carefully!" Anesthesiology 121, no. 4 (October 1, 2014): A21. http://dx.doi.org/10.1097/01.anes.0000453527.83839.8e.

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Schuller, Kristin A., Bita A. Kash, and Larry D. Gamm. "Enhanced Transitions of Care." Journal for Healthcare Quality 39, no. 2 (2017): e10-e21. http://dx.doi.org/10.1097/jhq.0000000000000063.

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Pinkowish, Mary. "MANAGING TRANSITIONS IN CARE." AJN, American Journal of Nursing 107, no. 2 (February 2007): 72C—72D. http://dx.doi.org/10.1097/00000446-200702000-00029.

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Beach, C. "Emergency Care Transitions: Response." Academic Emergency Medicine 10, no. 10 (October 1, 2003): 1143—a—1144. http://dx.doi.org/10.1197/s1069-6563(03)00387-7.

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West, Natalie E., and Peter J. Mogayzel. "Transitions in Health Care." Pediatric Clinics of North America 63, no. 5 (October 2016): 887–97. http://dx.doi.org/10.1016/j.pcl.2016.06.010.

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Hohl, Dawn. "transitions IN HOME CARE." Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional 27, no. 8 (September 2009): 499–502. http://dx.doi.org/10.1097/01.nhh.0000360926.49227.81.

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Lett, James. "Idolatry in Care Transitions." Caring for the Ages 19, no. 8 (August 2018): 12. http://dx.doi.org/10.1016/j.carage.2018.07.010.

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Coleman, Eric A., Carla Parry, Sandra Chalmers, and Sung-joon Min. "The Care Transitions Intervention." Archives of Internal Medicine 166, no. 17 (September 25, 2006): 1822. http://dx.doi.org/10.1001/archinte.166.17.1822.

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