Key Terms

care coordination

the deliberate organization and integration of health care services across different providers and settings to facilitate the delivery of holistic and continuous care to individuals and populations

care fragmentation

the division and disconnection of health care services and providers, leading to disjointed and uncoordinated client care

care transition models

strategic frameworks designed to improve the coordination and continuity of health care as clients transfer between different locations or different levels of care

care transitions

critical junctures in health care where individuals move from one health care setting to another or experience changes in their care needs

discharge planning

a transitional care process that aims to ensure a smooth transition for a client from a hospital or other health care setting to their home or another facility (such as a rehabilitation center, nursing home, or hospice)

medication reconciliation

the process of comparing a client’s medication orders to all the medications that the client has been taking

polypharmacy

taking many medications to treat ailments and additional medications to treat medication side effects

teach-back

teaching technique that involves asking the client or family to explain in their own words what they need to know or do about the client’s health to ensure the client and their family understand the information

transition of care

the movement of clients from one health care setting to another or from one level of care to another

transitional care

a comprehensive and coordinated set of actions designed to ensure the safe and smooth transfer of clients, encompassing a range of services and interventions aimed at supporting individuals as they move from one health care provider or facility to another or from one stage of care to another, such as from hospital to home or from acute care to rehabilitation

universal transfer tool

tool or form that helps ensure that essential information, such as client medical history, current medications, diagnoses, and care instructions, is accurately and comprehensively communicated between different health care settings and providers