Effective Transitions Between Care Settings

Unnecessary and avoidable care transitions can result in adverse outcomes, especially among older adults and people with multiple chronic conditions. Concerns about care transitions between acute and long-term services and supports (LTSS) settings have been raised since at least the 1990s. More recently, studies have emphasized the growing need to address care transitions from nursing homes to community-based settings, as well as to divert people from nursing homes. This In-Brief looks at six ways states can measure and improve effective transitions.