Transitions between care settings are fraught with errors that can lead to unnecessary suffering for patients and families, frustration for clinicians, and avoidable expenses for providers. Organizations nationwide need to pull together to create a seamless care system for patients living with multiple chronic conditions. Dr. Joanne Lynn explains why the issue of care transitions is paramount in endeavors to improve care of frail elders, and others living with advanced chronic conditions. This is the first of a 12-part video “how-to” series in which Dr. Lynn provides an overview of the issues, describes quality improvement efforts underway, and gives tips for clinicians and communities ready to get started in their own settings.
Key words: care transitions, frail elders, quality improvement, Joanne Lynn