Rethinking healthcare transitions and policies: Changing and expanding roles in transitional care

The breakdown of care transitions between various healthcare facilities, providers, and services is a major issue in healthcare, and accounts for over US$15 billion in healthcare expenditures annually. The transition between inpatient care and home care is a very delicate period where, too often, chronically ill patients get worse and wind up back in the hospital. This re-admission roller coaster is due in part to weak transitional care planning compounded by poor communication and coordination between healthcare providers, patients, and caregivers. The lack of a health information network and the resulting gap in transitional care exacerbates the incidence of preventable errors, increases the number of inpatient re-admissions, and adds to the rising cost of healthcare. Care navigation models provide a viable solution to address the unique characteristics of each patient transition and to prevent the current gap in care delivery. These models offer a framework for patient information exchange, interdisciplinary provider services, resource integration, and multifaceted interactive programmes for patient education. Currently, payment structures and procedural disagreements between the various service providers hinder the widespread implementation of care navigation models. In order to address the escalating cost of re-admissions and medical errors resulting from inadequate healthcare transitions, every effort should be made to dismantle these internal barriers, standardize goals, and assess and customize navigation models.