Care Transitions in Complex Patients

ABSTRACT

Healthcare delivery is transforming from hospital-centric episodic care to a more patient-centric comprehensive and continuing care that caters to the changing needs of an ageing population and finite healthcare resources. The transition period during which patients move between healthcare settings is a period of vulnerability that requires well-executed care transitions. The relatively less-developed primary, intermediate and long-term care sector further underlines the importance of good transitional care. This article serves to introduce Family Physicians to the importance of transitional care, its broad concepts and a simple framework to help manage complex patients comprehensively in any Family Medicine practice setting.