Six Strategies to Reduce Patient Discharge and Care Transition Risk

By Ann Fiala and Barbara Ricci

The U.S. healthcare staffing crisis is severely impacting patients. Among other effects, it is causing a dramatic increase in the length of expensive hospital stays.

Four in 10 hospitals have struggled to appropriately discharge patients due to staffing shortages (Reed, 2022). Moreover, 86% of hospitals say COVID-19 has made it harder to secure placement for discharged patients. With the lack of postacute care staffing, health systems are under pressure to extend the length of hospital stays—making the cost of care dramatically more expensive.

Even before COVID-19, though, the U.S. healthcare system was experiencing alarming rates of medical errors and claims resulting from ineffective care transitions. Sixty-one percent of claims associated with an alleged medical error from 2017 to 2019 occurred during external transitions: a patient being transferred from one facility to another facility or medical office (Hanscom et al., 2021). Transfers to or from acute care settings, long-term care, rehabilitation centers, home, or medical offices are of particular concern.

Since transitions between healthcare settings are more likely to result in indemnity payments and significant patient harm, clinicians, quality leaders, and other healthcare professionals should consider the following key strategic focus areas to reduce care transition risks.

  1. Empower and understand the patient

First, start discharge education at the beginning of treatment and reinforce it often. This will help ensure that the patient is as prepared as possible. Second, provide written discharge instructions in plain language. Implement “teach-back” strategies to ensure both the patient and caregivers understand the instructions. Always provide an opportunity for the patient and family to ask questions. Finally, adopt a follow-up system to ensure that the patient has no additional questions and is adhering to their care plan as intended.

  1. Individual and team accountability

The hospitalist model can improve coordination during care transitions. However, staffing challenges and inconsistencies between organizations can complicate handoffs. As a result, it is vital to assess your organization’s hospitalist model and ensure that everyone is aware of their roles and responsibilities. Primary care doctors and hospitalists should act as the quarterback for the patient, while consulting specialists should clarify their role on the team.

  1. Monitoring and medication management

Standardize all processes related to patient handoffs, including checklists and handoff tools that provide consistent information. It is also essential that providers proactively partner with organizations within their community to evaluate the quality of patient transfers. Additionally, implementing and monitoring medication reconciliation processes is imperative. Consider investigating pharmacist-led care transition programs, which may help your organization enforce regular communications between a patient’s clinicians and pharmacist.

  1. Provider-patient communication

To help ensure everyone is on the same page regarding the care plan, confirm that providers discuss all findings, whether expected or unexpected, with the patient and designated caregiver in addition to key members of the care team. The provider who is ultimately responsible for follow-up care should be clearly identified and receive all instructions, including discharge documents, test results, and follow-up expectations.

  1. Vulnerable patients

Readmissions among vulnerable populations can be difficult to prevent. For this reason, it is vital to review readmission data broken down by payer. Evaluating non-Medicare readmissions may identify patterns in underinsured or Medicaid populations. In addition, performing an inventory of postacute and community-based services may reveal additional clinical, behavioral, and social service resources that could support a patient’s transitional care needs. If possible, create a “high risk for readmission” flag in the electronic medical record (EMR) to make it easier for the clinical team to intervene before readmission occurs. Finally, to better help the patient self-manage their care, implement a “whole person” needs assessment to identify unmet social and behavioral health needs.

  1. Diagnostic accuracy and clinical decision-making

Ensure that the whole patient is being treated regardless of the admitting diagnosis or procedure. When possible, have the EMR include hardwired protocols that address abnormal findings, including incidental findings. Clearly identifying and communicating who is responsible for ongoing follow-up is key to avoiding diagnostic error and patient harm.

Healthcare providers must often rely on colleagues with whom they have little synergy and perhaps no relationship, yet by focusing on these key strategic areas, they can take an active role in ensuring seamless care transitions and reducing the risk of medical errors and claims.


Hanscom, R., Small, M., Fiala, A., Bennett, P., & Ricci, B. (2021, September 14). Care transitions: Through the lens of malpractice claims. Coverys.

Reed, T. (2022, May 11). Staffing shortages slam hospitals. Axios.

Ann Fiala is a senior risk specialist with Coverys. Barbara Ricci is a senior analyst with Coverys.