Transitions are a complicated and vulnerable time for patients, particularly for those with complex care needs. This review examines the literature around care transitions and insights from patient and family advisory councils. The authors recommend standardizing the process for veterans with complex conditions and suggest focus on the use of real-time information exchange, documented care plans, and engaging patients and their families in transitions.

Drawing from qualitative interviews with pharmacists and social workers, investigators determined that access to rural health services is affected by individual concerns about privacy and confidentiality, and by the reputation and value system of the health care worker.

The investigators surveyed patients regarding the coordination of their postdischarge care and identified problems with coordination across settings, within settings, and between patients and providers.