Maintaining patient health after a hospital stay...
RARE - Reducing Avoidable Readmissions Effectively

Transition Communications

Transition communication is one of five key areas known to reduce avoidable readmissions. Hospitals working on this topic will focus on ensuring that effective communication occurs between sending and receiving caregivers working with the hospital, e.g., home care, home, primary/specialty care, skilled nursing facility or rehab. Interventions may include processes for transferring information, providing discharge summaries in a timely manner, defining accountability for care, communication of the plan of care, methods for talking directly with sending or receiving caregivers, definition of key information which may include current health status, follow-up needs, pending test results, red flags, medications and special patient needs.

Transition Communications - Tools and Resources >

Typical Transition Failures

  • Poor documentation of hospital care (evidence-based care missing or incomplete)
  • Medication discrepancies
  • Discharge plan not communicated in a timely fashion, or does not adequately convey important anticipated next steps
  • Poor communication of the care plan to the nursing home team, home health care team, primary care physician, or family caregiver
  • Current and baseline functional status of patient rarely described, making it difficult to assess progress and prognosis
  • Discharge instructions missing, inadequate, incomplete, or illegible
  • Patient returning home without essential equipment (e.g., scale, supplemental oxygen, or equipment used to suction respiratory secretions)

Best Practices/Strategies for Improvement


  • All transitions must include records that contain core elements. Additional elements also should be included as appropriate for individual patients
    • The facility requires and has a designated form that contains core elements for each appropriate transition setting
  • Hold team members accountable when the agreed upon process and elements are not completed regardless of whether or not an adverse event occurs
  • Communications between practitioners, and between practitioners and patients and families/caregivers, is secure, private, Health Insurance Portability and Accountability Act compliant, and accessible to patients and those practitioners who care for them.


  • At every point during care transition, patients and their families know who is responsible for care and how to contact the caregiver
    • The facility requires and has a designated mechanism of communication to provide caregiver contact information to patients and their family
  • Transition responsibility belongs to the sending clinicians and organizations until the receiving practitioners confirm assumption of responsibility
    • Transferring facilities have a process in place to confirm assumption of responsibility by receiving facility
  • The sending practitioner is available for clarification with issues of care within a reasonable time frame after the transfer has been completed, and this time frame should be based on the conditions of the transfer settings

Coordination of Care

As the hub of care, coordinating clinicians must provide timely communication to other care providers

  • Establish timelines for communication and information exchange between sending and receiving practitioner based on urgency and needs of the patient
  • Establish format of communication and information exchange among care settings

Family Involvement

  • Patients and families must be involved in providing information needed to identify patient's medical care home and coordinating clinicians
    • Engage patient and family in transition process recognizing the central role patient and family play in executing transition care support plan
  • A section on the transfer record is devoted to communicating a patient's preferences, priorities, goals, and values (eg, the patient does not want intubation)
Patients and family members
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RARE is a campaign lead by the Institute for Clinical Systems Improvement, the Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.