What is transitional care in Nursing?

Transitional care refers to the various activities that nurses engage in to maintain the continuity of healthcare when a patient moves from one setting or service to another. Often, this is when patients transition from a hospital setting to their home, but it can also apply to children moving into adult care or a patient with a chronic illness whose care needs change, for example. Transitional care ensures a smooth journey from one setting or service to another, preventing disruptions to care and minimizing risk to the patient. Here’s a closer look at how transitional care works:

Elements of care transition

Depending on the patient’s needs and their level of complexity, as well as the condition or nature of the transition, each transition can differ slightly. Here are the elements of a typical care transition:

  • Discharge planning
  • Discharge teams
  • Home support within discharge teams
  • Community-based support
  • Assessors
  • Logistical arrangements
  • Education of family and carers
  • Medical paperwork, information and medications stay with patients
  • Care interventions to facilitate the transition

Successful transitions require healthcare professionals to collaborate across organizations with the support of leaders. They also require cooperation and integration between acute and community care. 

Who completes care transitions?


Various medical professionals are involved in care transitions. Exactly which professionals work on the transition depends on the patient and their needs. Nurses often support these transitions, such as those who’ve completed an online adult-gerontology nurse practitioner program. These courses train students on the unique health concerns of adults of all ages, helping them improve the functionality and quality of life of adults in both community-based and home settings. This makes them ideal healthcare professionals for facilitating the transition from hospital to home-based care. 

Types of transitional care

Here are some types of transitional care:

Transition to a different level of care

Patients often require various kinds and levels of treatment throughout the development of chronic conditions or as their needs change. For example, children receiving care may reach the age where they require adult care, which requires a transition in terms of the location and care provided. Those with chronic illnesses may also require transitional care as their needs evolve, as they may need to transition into a different ward or require different equipment. 

Transition to a different location 

Those transitioning from hospital-based care to home care need transitional care to support the process. This can involve various activities depending on the needs of the patient, as there may be equipment to move or training to be delivered so that care can continue as normal. Acute care providers must cooperate with community-based care providers to safely transition patients and ensure they have access to all the required services. All planning must be done beforehand to ensure an efficient and effective transition. 

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