Transitions of care are crucial moments for patients, often fraught with risks, but palliative care providers can help ensure that the changes go more smoothly.

One way of doing this is through transitional care. Transitional care is a dynamic and highly personalized type of care that provides care services to assist patients as they move between different levels of health care. This may include a patient transitioning from a hospital setting to another care facility, or to their home.

Transitional care helps bridge service gaps and enhances communication as patients move between health care settings, according to Dr. Diane Meier, founder of the Center to Advance Palliative Care (CAPC).

“The time-pressured environment of the hospital – and all health care settings for that matter – makes it difficult to make sure that what we thought we were communicating was understood. The field of transitional care arose as an effort to address this problem,” Meier told Palliative Care News in an email.

A transition of care begins with the development of a transition plan. This should occur before a patient is discharged from a care setting and includes identifying the care environment they are moving to, their care providers and specific care instructions.

When palliative care providers are involved, they become an essential part of managing a transition. They ensure that patients and families clearly understand their care plan, their goals of care and the role that each provider plays. And the palliative care team is often at the center of the coordination effort for a transition, according to Skelly Wingard, CEO of By the Bay Health, a nonprofit network that provides hospice and palliative care services.

“I liken palliative care to the hub on a wheel, and all of the different specialties and care providers are the spokes,” Wingard told Palliative Care News. “It’s often the central hub, coordinating multiple specialists, multiple care settings and support services.”

Patients face risks during transitions due to a potential break in the continuity of care. A 2023 study by Frontiers in Public Health found that patients are more vulnerable during transitions, with 1 in 5 experiencing negative outcomes.

Patients are susceptible to worsening symptoms during transitions but insufficient communication can also create complications. This may include medication errors, missing follow-up appointments and a patient or caregiver misunderstanding care instructions, all of which can lead to hospital readmissions, according to a 2024 study from the University of California Riverside. 

To mitigate risks, care providers need to consider several factors. For patients who are transitioning to a home setting, Meier said that understanding the patient’s living situation is important. Do they live alone? If the patient lives with someone, is that person able to support the patient’s care needs?

Communicating directly with the patient is another important factor. Meier suggests ensuring a member of the transition team is assigned to ask specific questions about a patient’s status and well-being.

“Questions include asking about falls, bowel and bladder function, especially constipation,” Meier said. “Whether the patient understands, and can tell you what medications they are taking and for what purpose? Do they seem confused or in pain?”

For older adults with chronic conditions, a strategic approach to transitional care is essential to ensure a patient’s safety, health and quality of life. Strategies palliative care providers use to help improve care transitions include ensuring the safe use of medications, engaging and educating patients and their family, and managing follow-up care.

But Wingard explained that one of the most important strategies is building strong interdisciplinary teams.

“There’s this trust and relationship building that has to happen with all of the care team that sits in different spaces and places,” she said. “And I would say that’s probably the biggest kind of strategic differentiator right there.”

Meier and Wingard said they believe that palliative care transitional practices could be more widely used. Meier attributes this narrowed use to cost.

“An effective transitional care program requires 24/7 coverage so people can get help after hours, and the ability to send a clinician to a patient’s home,” said Meier.

She explained that when insurance fails to pay for these types of services, patients end up calling 911 or going to the emergency room. 

But when patients do have access to robust palliative care during transitions, Wingard said she believes the outcomes are much more favorable.

“I do feel like if you’re in the hands of a palliative care team, your plan of care and coordination of care has a higher probability of being proactively communicated to your various care team members across the continuum and in various specialties,” Wingard said

One barrier is the dearth of trained palliative care specialists. However, other types of clinicians can receive training in palliative care principles, according to Meier.

“Since there are many fewer trained palliative care specialists in the United States than are needed,” said Meier. “One excellent strategy is to provide training to transitional care staff on core palliative care principles and practices.”