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The Concept of Transitions of Care

Clinical Nursing Practice Problem

A fragmented health care system requires an increase in continuity of care across health care levels. Care transition is considered as the extension of health care of the patient when one is transferred across different health care levels. As such, older people are seen as major consumers of health care services where they are sensitive to negative incidents and serve as a target for alterations to lessen medical costs.

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In order to meet their needs, it is essential to focus on care transition to the patients’ experiences of the durability of care during care transition. Furthermore, “theories such as person-centered care, based on values of mutual respect, self-determination, and understanding” might be applied as well (Rustad, Furnes, Cronfalk, and Dysvik, 2016, p. 769). Therefore, the success of care transition of older patients across health care levels contributes to well-functioning and continuous residential treatment and care.

Clinical Nursing PICOT Question

Multiple types of research on this issue facilitate the enhanced focus on age-related differences among older patients during care transition.

How do patients of 80 years and older (P) experience continuity in treatment and care (O) during care transition (I) from hospital to municipal health care services (C) 1–2 weeks after discharge from hospital (T)?

Define PICOT Elements

  • P- (patient population/patients of interest): patients 80 years old and older
  • I- (Intervention): care transition/level of care.
  • C- (Comparison): the transition from hospital to municipal health care services
  • O- (Measurable outcome): how patients experience continuity in treatment and care/ how do they experience participation in planning the care transition
  • T- (Time frame in months): 1–2 weeks after discharge from hospital

Evidence Retrieval Process and Summary

Transitions in care imply the process of patient movement from one healthcare setting or provider to another or from one unit to another within the same location. In addition, these actions include the extensive set of actions performed in a coordinated manner (Thomson et al., 2015). The evidence-based study analysis showcased that quality of care and patient safety are adversely affected in case of poor implementation of care transitions. The inefficient coordination of such transitions leads to fragmentation of healthcare delivery. The evidence-based study is crucial for identifying different aspects of the care transition process and presenting it as a complex

process with many challenges for older patients, clinicians, and the health care system. With that said, the emphasis should remain on older patient’s participation in planning care transition, the role of communication, and the responsibilities that can be organized to develop advanced policies, as well as improved practice in serving older patients.

Implications of the Evidence

The research demonstrated that older patients are willing to participate in decision-making with regard to their care transition. However, the inequity in power between the patient and care providers, they remain vulnerable and, hence, might feel hesitant to communicate their needs. Rustad et al. (2016) suggest that there are relational elements, which might impede the possibilities for patients’ participation.

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Furthermore, older patients consider themselves with a cultural perception of age as being old, slow, and disempowered. Thus, it reveals the tensions surrounding the conflicting shared needs of the patient and the health care setting. Older patients are seen as the vulnerable sector within the care transition process. Hence, it is vital to focus on their needs and equip professionals with the necessary insight to meet the best and secure care durability.


Rustad, E., Furnes, B., Cronfalk, B., & Dysvik, E. (2016). Older patients’ experiences during care transition. Patient Preference and Adherence, 10, 769-779. Web.

Thomson, B., Gorospe, G., Cooke, L., Giesie, P., & Johnson, S. (2015). Transitions of care: A hematopoietic stem cell transplantation nursing education project across the trajectory. Clinical Journal of Oncology Nursing, 19(4), E74-E79. Web.

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