Care Transitions

Time to read: 2 minutes.

Managing transitions is a key aspect of care coordination and helps ensure that participants undergo a seamless transition from one setting to another. These transitions may be from one health care setting to another, from a health care setting to home, or between health care professionals. Care coordination during transitions is based on a comprehensive plan of care and the availability of providers who are well-trained and have current information about the participant’s goals, preferences, and clinical status.

Managing transitions includes:

  • Handling logistical arrangements,
  • Education of the participant and family, and
  • Coordination among the health professionals involved in the transition.

This helps to ensure gaps in care are mitigated and the appropriate information is transferred during handoffs across settings and providers.1

Dually eligible beneficiaries are a demographically diverse population, often with multiple health care, behavioral health, long-term services and supports, and social service needs. Many face adverse social risk factors that may affect health status, such as housing insecurity and homelessness, food insecurity, inadequate access to transportation, poverty, and low health literacy.2 This variety of needs and social factors require navigating different systems and settings of care, often leading to increased transitions. Resources for Integrated Care has developed resources to help providers and plans serving dually eligible beneficiaries in supporting care transitions

1 (2013) Managing Transitions, Resources for Integrated Care. Retrieved from

2 Barth, S., Silow-Carroll, S., Reagan, E., Russell, M., Simmons, T. (2019) Care Coordination in Integrated Care Programs Serving Dually Eligible Beneficiaries – Health Plan Standards, Challenges and Evolving Approaches. Report to the Medicaid and CHIP Payment and Access Commission.

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