The target population is an ideal group for medication reconciliation study because the patients usually have long medication lists, multiple care providers, and frequent transition between the hospital, clinic, and home care settings.
In 2004, the cost for hospital readmissions among Medicare recipients was estimated to be US $17.4 billion. 1 Accordingly, the Affordable Care Act includes multiple provisions designed to improve care transitions.
Unfortunately, our research did not evaluate potential differences in diabetes self-care behaviors as they might pertain to the nature of the patient-diabetes team relationships and continuity of care versus transitioning between multiple care providers.
Primary-care-based medical homes may facilitate care transitions for persons with multiple chronic conditions (MCC) including serious mental illness.
A successful transition plan recognises transition as a multifaceted process that engages multiple care providers and accommodates a patient's condition, chronological age and developmental stage. 2 4 10 11 Many healthcare organisations, including hospitals, have developed transition programmes to help youth exit the paediatric system.
Successful transition outcomes require coordination across multiple care providers, which necessitates well-articulated health system strategies.
Medication errors are common and cause serious health issues during care transitions, particularly for older adults with multiple chronic conditions.
In Phase 2, we undertook a one-year data collection phase using multiple tools including the T3 with a minimum target of 400 residents experiencing care transitions.
3. Electronic health record systems that allow for providers across multiple health care settings to access pertinent, up to date patient information to facilitate care transitions from one provider or setting.
Our study provides insights from the perspectives of multiple clinicians that have important implications for health care leaders and clinicians in their efforts to enhance inter-organizational care transitions.
