By Eric Andrew Kristof, RN, CAHIMS | Healthcare IT Professional | HIMSS Arkansas Chapter Member
About This Series: The HIMSS Word of the Day is a running blog series drawing from the HIMSS Dictionary of Health Information and Technology Terms, Acronyms, and Organizations, 6th Edition (2025) — the authoritative reference for healthcare IT professionals and the primary study resource for CAHIMS and CPHIMS certification. Each post paraphrases the term in plain language, grounds it in real-world healthcare IT context, and adds a bedside nursing perspective you won’t find in a textbook.
📖 The Term: Care Transitions
Source: HIMSS Dictionary of Health Information and Technology Terms, Acronyms, and Organizations, 6th Edition (2025)
🔍 Plain-Language Definition
Care transitions, also called transitions of care, are the moments when a patient’s care passes from one provider, team, or setting to another.
The HIMSS Dictionary frames a care transition broadly. It includes any point where a patient goes to or comes back from a location, or makes contact with a health professional, in order to receive care. Moves between home, the hospital, and residential care settings count, and so do visits with different outpatient providers. In the Dictionary’s framing, each change of setting or provider is a new transition.
That broad view matters because transitions are where information is most likely to be lost. The sending team knows the patient well; the receiving team often starts with only what the sending team managed to communicate.
| Transition Type | Example | Key Information at Risk |
|---|---|---|
| Between Settings | Hospital discharge to home or to a skilled nursing facility | Medication changes, follow-up appointments, pending test results |
| Within an Organization | Emergency department to inpatient unit, or ICU to step-down | Current assessment, active orders, recent events |
| Between Providers | Primary care referral to a specialist | Reason for referral, relevant history, prior results |
| Into or Out of Home Care | Hospital to home health, or home to hospice | Care plan, equipment needs, caregiver instructions |
⚠️ Exam Alert: A care transition is a change of setting or provider. A handoff is the transfer of responsibility and information between clinicians, which can happen inside one unit at shift change. Discharge planning is the process that prepares a patient for leaving a facility, and care coordination is the ongoing organization of care across participants. Expect questions that use these terms side by side.
🌐 Why It Matters: Real-World Healthcare IT Context
Transitions are risky by nature. In a frequently cited 2003 study in the Annals of Internal Medicine, 19% of patients discharged from a medical service experienced an adverse event after leaving the hospital, and adverse drug events made up about two-thirds of them. Many of those events were judged preventable or could have been made less severe.
Well-designed transition programs can help. In the Project RED (Re-Engineered Discharge) randomized trial, patients who received a package of discharge services had lower hospital use within 30 days than those who received usual care. In the Care Transitions Intervention trial, coaching older patients and their caregivers through the transition lowered rehospitalization rates at 30 and 90 days. AHRQ publishes a free toolkit based on Project RED.
Payment policy adds pressure. CMS’s Hospital Readmissions Reduction Program reduces payments to hospitals with higher-than-expected readmissions for selected conditions, which has made transitions a board-level concern for many health systems.
Health IT supports nearly every step. Discharge summaries and transition of care documents built on C-CDA move clinical information to the next provider. Health information exchange and event notifications tell primary care teams when their patients are admitted or discharged. Medication reconciliation tools compare home, inpatient, and discharge medication lists. Patient portals carry after-visit instructions and follow-up reminders.
Where transitions break down:
- Discharge summaries that arrive late or not at all
- Medication lists that conflict between settings
- Test results that return after discharge with no clear owner
- Follow-up appointments that are recommended but never scheduled
- Instructions written above the patient’s health literacy level
- Receiving facilities that are not connected to exchange networks
What safer transitions include:
- Structured medication reconciliation at admission, transfer, and discharge
- Timely, standards-based transition documents sent to the next provider
- Admission and discharge event notifications routed to care managers
- Follow-up appointments scheduled before the patient leaves
- Teach-back education with the patient and caregiver
- Clear ownership of pending results after discharge
🏥 The Nurse’s Perspective: Clinical, Bedside, & Workflow
Nurses are present at nearly every care transition, and they often carry the most complete picture of the patient across it.
At the Bedside
Discharge teaching is one of the most important transition tasks nurses perform. Nurses review new and changed medications, warning signs, wound or device care, and follow-up appointments, then use teach-back to confirm the patient and caregiver understand. A patient who leaves unsure which home medications to stop is at real risk, regardless of how complete the paperwork looks.
Nurses also catch transition problems early. When a patient arrives from another facility with a medication list that does not match the transfer orders, the admitting nurse is often the first to notice and raise it.
In Clinical Workflow
Inside the hospital, transitions happen constantly: from the emergency department to a unit, from the operating room to recovery, and from intensive care to a step-down unit. Nurse-to-nurse report at each step is a handoff that supports the larger transition, and structured formats help keep it complete.
Transitions to post-acute care rely heavily on nursing documentation. Skilled nursing facilities and home health agencies need functional status, skin and wound assessments, recent vital sign trends, and the patient’s response to education. When that information is clear in the transfer packet or exchanged electronically, the receiving team can plan care from the first hour.
In EHR Implementation (Go-Live Perspective)
During an Epic Go-Live, discharge workflows are among the most visible changes for nurses. Discharge navigators, medication reconciliation activities, after-visit summaries, and transfer reports all change at once. At-the-elbow support analysts often help nurses find where to review discharge medication changes, print or send the after-visit summary, and confirm that the discharge summary has gone to the next provider.
Transition interfaces deserve attention in testing. Event notifications, transition of care documents, and referrals to post-acute partners should be validated with real scenarios so that information actually arrives at the receiving facility after Go-Live.
🎓 CAHIMS / CPHIMS & HIMSS Perspective
CAHIMS Exam Domain Mapping
Care transitions connect clinical workflow, interoperability, and value-based care:
| CAHIMS Domain | How Care Transitions Appear |
|---|---|
| Healthcare & Technology Environments | Readmission penalties; value-based payment; post-acute care; patient safety research |
| Clinical Informatics | Medication reconciliation; discharge teaching; handoff tools; after-visit summaries |
| Healthcare Information & Systems Management | C-CDA transition documents; health information exchange; event notifications; referral management |
| Management & Leadership | Readmission reduction programs; partnerships with post-acute providers; measuring follow-up completion |
Key Terms to Know Alongside Care Transitions
- Medication Reconciliation — comparing a patient’s medication lists across settings to resolve omissions, duplications, and conflicts
- Discharge Planning — the process of preparing a patient and family for safe departure from a facility
- Readmission — an unplanned return to the hospital within a defined period after discharge, often 30 days
- Hospital Readmissions Reduction Program (HRRP) — the CMS program that reduces payments to hospitals with excess readmissions for selected conditions
- Teach-Back — an education method in which patients explain instructions in their own words to confirm understanding
- Handoff — the transfer of responsibility and information between clinicians or teams
HIMSS Organizational Position
HIMSS treats care transitions as a practical test of interoperability: information has to follow the patient across settings to be useful. Its Nursing Informatics Community and its interoperability policy work both address the tools and standards that support safe transitions. Members can find related education and research through the HIMSS Resource Center.
🔗 Explore Further: External References
- AHRQ — Re-Engineered Discharge (RED) Toolkit https://www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/index.html
- CMS — Hospital Readmissions Reduction Program https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp
- AHRQ PSNet — Readmissions and Adverse Events After Discharge https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
- Forster et al. (2003), Annals of Internal Medicine — Adverse Events Affecting Patients After Discharge https://pubmed.ncbi.nlm.nih.gov/12558354/
- Jack et al. (2009), Annals of Internal Medicine — A Reengineered Hospital Discharge Program https://pubmed.ncbi.nlm.nih.gov/19189907/
- Coleman et al. (2006), Archives of Internal Medicine — The Care Transitions Intervention https://pubmed.ncbi.nlm.nih.gov/17000937/
Term source: HIMSS Dictionary of Health Information and Technology Terms, Acronyms, and Organizations, 6th Edition (2025). All definitions in this series are paraphrased for editorial purposes. Readers are encouraged to consult the primary source for exact language.
Eric Andrew Kristof, RN, CAHIMS is a Healthcare IT professional and HIMSS Arkansas Chapter member based in Hot Springs Village, AR, with hands-on Epic Go-Live experience and a diverse healthcare and IT background. He writes at kristof.org at the intersection of clinical care and healthcare technology.
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