Why this matters: Transitional care is a critical bridge because the period immediately following hospital discharge is one of the most vulnerable times for a patient.  It matters because it addresses high-risk gaps in care such as medication errors or lack of follow-up that frequently lead to patient harm and avoidable hospital re-admissions.

Care transitions are especially risky for older adults with chronic conditions, and approximately 1 in 5 patients experience adverse events during the hospital-to-home transition.

Key risks during transition:

• Readmission within 30 days

• Medication discrepancies and missed follow-up care

• Fatigue, confusion, poor appetite, and loss of mobility after discharge