What Families Should Know About Care Transitions

A care transition is any move from one setting or team to another: hospital to rehabilitation, rehabilitation to home, or home to a new specialist. Each handoff is a point where information can be lost or misunderstood, which is why families often feel overwhelmed during transitions.

Why transitions feel hard

• New teams may not know your history yet.
• Instructions arrive quickly and in large amounts.
• Several people may be responsible for different parts of care.
• Families may be in different places and receiving different information.

How to prepare

Ask who is coordinating. Find out who your main point of contact is in the new setting.

Ask for written instructions and keep them together.

Review the plan out loud. Repeat back what you understood and ask what to do if something changes.

Clarify follow-up. Ask which appointments are needed and who will schedule them.

Keep medications clear. Ask the prescriber or pharmacist about any changes, and keep an up-to-date list.

Include the family. Share the plan with the people who will be helping, and choose one person to keep notes.

When to ask for help

If you're not sure you're ready, say so to the care team. An independent RN advocate can also help you prepare questions and stay organized during transitions.

This article is general education and is not medical advice.