In the United States, the traditional model of healthcare delivery is divided into discrete episodes of care. Patients frequently move between multiple settings and providers without a dedicated person or team assuming responsibility for maintaining quality of care or managing the transitions-of-care process.

Without a single point linking healthcare systems and providers, the efficiency of care coordination during a transition is reduced. This lack of effective coordination can have serious consequences, many of which can likely be reduced or avoided.

The Role of Long-term–Care Facilities in Transitions of Care