Changing the culture of practice to support care transitions - Why now?

Our healthcare system emphasizes brief episodes of treatment for acute medical conditions, followed by poorly coordinated care delivery. Care transitions are a particularly vulnerable time for older adults and those with complex needs. Developing new models to improve care coordination across settings is an opportunity to reduce re-hospitalizations and other objectives tied to patient safety and improving care quality during transitions. This article explores the challenges to changing our current culture during transitions, presents new frameworks for culture change, and provides examples of transitional care interventions that are evolving the culture into one that encourages collaboration, problem-solving, and accountability to improve patient outcomes.