One of the things that has stayed with me throughout my career in healthcare is how vulnerable a patient can become when responsibility for their care moves from one organization to another. We often think about quality within the walls of a hospital, nursing home, dialysis facility, physician practice, or home health agency. Yet some of the most important moments in a person’s care happen between those settings, when information has to travel with them, medications need to be reconciled, follow-up has to be arranged, families need to understand what comes next, and the receiving team needs a clear picture of what has already happened.
Recent CMS activity is bringing more attention to that part of the care journey. An updated skilled nursing quality measure looks beyond whether someone was discharged back to the community and considers what happens during the weeks that follow, including whether that individual experiences an unplanned hospital readmission. At the same time, rural health investments around the country are supporting stronger regional networks, better data exchange, transportation, telehealth, and coordination among hospitals and community providers. In dialysis care, hospitalization and readmission remain important measures of quality and care coordination.
I think these developments reinforce an important point: a successful transition is not completed when the patient leaves the building. Having led healthcare organizations on different sides of these transitions, I know how easy it is for each provider to do its part well and still leave gaps in the overall experience. A hospital may provide excellent acute care, but the next setting needs timely and useful information to continue that care safely. A nursing home may stabilize a resident and prepare them to return home, but that success depends partly on whether medications, follow-up appointments, support services, and family expectations are clear. For someone receiving dialysis, a hospital stay can create changes that need to be communicated quickly and accurately back to the dialysis team.
The patient experiences all of this as one healthcare journey, even when our organizations experience it as several separate episodes of care. That is why strong transitions require more than a discharge packet. They depend on relationships between providers, clear expectations about what information needs to move with the patient, reliable communication, and teams that understand what could put that individual at risk during the next stage of care. Technology can certainly help, especially as healthcare systems invest more heavily in interoperability and regional connectivity, but technology cannot replace shared responsibility.
At Qsource, we have the opportunity to see this issue from many different perspectives through our work in long-term care, ESRD, managed care quality, rural health, and quality improvement. The settings may be different, but the importance of coordination is remarkably consistent. When information is incomplete or follow-up is unclear, patients and families are often the ones left trying to connect the pieces. When providers communicate well across settings, care becomes safer and the experience becomes much less confusing.
I also believe healthcare leaders have an opportunity to look beyond what happens inside their own organizations. Quality does not stop at the door, and neither should our responsibility for helping the next provider succeed. Better transitions require us to understand where patients came from, where they are going, and what the next team needs from us to continue the work.
We talk a great deal about creating a more connected healthcare system. Care transitions are where patients find out whether we have actually built one. The handoff is not the space between care. It is part of the care.