Value-based payment (VBP) reforms have reshaped US health care by shifting accountability from volume to value. In this article, we evaluate how 4 major VBP models-including public reporting programs, pay-for-performance models, episode-based payment models, and population-based payment models-intersect with care transitions of patients, including transitions from emergency department to hospital, interhospital transfers, and hospital-to-skilled nursing facility discharges. We highlight how incentives in VBP models alter clinician thresholds, referral patterns, and postacute care strategies, and importantly, highlight the implications for cost, quality, and equity in health care delivery.

Care transitions remain high-risk periods, with up to 28% of patients experiencing adverse events (AEs) or readmissions within 30 days of discharge. This article examines digital innovations reshaping postdischarge care: synchronous telehealth for scheduled follow-up, remote patient monitoring for continuous surveillance between encounters, and artificial intelligence for risk prediction and clinical decision support. Evidence demonstrates these technologies can improve outcomes when integrated into redesigned care pathways with multidisciplinary coordination. Advancing technology-enabled postdischarge care requires value-based payment reform, equity-focused design, seamless workflow integration, and comparative effectiveness research measuring preventable AEs.

Communication and coordination between inpatient and outpatient clinical teams, patients, and caregivers are essential to effective care transitions. Frequently used strategies to promote communication include sending information, telephone calls, and asynchronous messages. Involvement of the interprofessional team, setting up postdischarge appointments prior to discharge, and navigation have been utilized to improve postdischarge care planning and execution. Most studies report single-site, pre-post interventions that as a whole have an inconsistent association with outcomes. Despite these limitations, engaging pharmacists, utilizing multicomponent approaches that can be adapted, and supporting shared understandings that enable coordinated action are key lessons for improvement.

Social determinants of health (SDOH) influence transition of care (TOC). The complex interactions of SDOH-such as those between education and economics-make research and interventions in this area challenging. However, evidence suggests that SDOH can help identify those at risk of poor TOC outcomes. High-risk groups include people with public or no insurance, those with low income or limited social support, and those who live in disadvantaged neighborhoods. Interventions such as improved health care access and enhanced social support may offer meaningful impact.

Care transitions among older adults are common and made more complex by multimorbidity, polypharmacy, frailty, and fragmented care. Transitions may be prompted by changes in clinical status, including the need for end-of-life care, or social status. Numerous interventions to predict, prevent, and improve care transitions for older adults have been tested. In this article, we will provide a high-level overview of common care transitions for older adults, reasons why an older adult may experience a care transition, outcomes specific to older adults, and proposed interventions.

This review article uses a case-based approach and an implementation science lens to guide readers in developing a broad understanding of the multilevel factors that impact the pediatric to adult health care transition process for adolescents and young adults.

Transitions of care, such as intrahospital handoffs and hospital discharge, are high-risk periods for adverse events like medication errors and diagnostic delays, often stemming from communication lapses and care fragmentation. Evidence-based strategies, including multidisciplinary team collaboration, standardized handoff protocols, and electronic health record tools, can mitigate these risks and improve patient safety. Emerging technologies, such as artificial intelligence and remote monitoring systems, offer opportunities to personalize care and provide real-time support. Engaging patients and families as active partners and addressing social determinants of health are essential to creating safer, patient-centered transitions that reduce preventable harm and improve outcomes.

A team-based approach can empower patients and family and facilitate successful postacute care transition. Focusing on early barrier identification and communication with the patient and family can improve outcomes.

Transitions of care are high-risk periods when it comes to medication safety. Hazards include medication discrepancies, nonadherence, inappropriate prescribing, and inadequate monitoring for medication-related problems. Several types of interventions have been implemented and evaluated. Recent and higher quality studies suggest that the most potent interventions are those that incorporate multiple components and are implemented in patients at highest risk (eg, elderly with polypharmacy and low health literacy). Widespread implementation is limited by the resource-intensity of these interventions. However, these interventions may be cost-effective under certain circumstances, especially when considering hospital over-crowding and payment systems based on quality, safety, and value.

Interhospital transfers (IHT) are indispensable for providing timely access to specialized services, particularly for rural populations and high-acuity conditions such as trauma, stroke, and myocardial infarction. However, IHTs introduce substantial risks, including transport complications, care discontinuity, increased costs, prolonged hospitalization, and elevated mortality. Although Emergency Medical Treatment and Labor Act and Centers for Medicare & Medicaid Services regulations establish baseline safeguards, coordination deficiencies persist. Centralized transfer centers, standardized documentation, and structured handoffs improve efficiency and safety, while health information exchange remains hindered by interoperability limitations. Enhanced coordination, standardization, data sharing, and care innovations are imperative to optimize outcomes.

Ineffective handoffs are associated with medical errors and adverse outcomes. Intrahospital handoffs occur at shift change, patient transfer, and service change. Handoff interventions often include structural interventions (eg, mnemonics, electronic tools, and protected time) and/or educational interventions. Many studies of handoff interventions demonstrate improvement in process measures or information transfer. One of the few studies to demonstrate a significant improvement in clinical outcomes is the I-PASS study. Future research should address the limitations of existing data and investigate emerging approaches to enhance patient handoffs, including the use of artificial intelligence as a novel model for improving intrahospital transitions of care.

This article describes best practices for hospital discharge transitions and reviews why health care teams should implement effective discharge planning strategies including interdisciplinary team collaboration, patient-centered education, and clear communication protocols. We review risk stratification tools for identifying patients at high readmission risk and evidence-based intervention bundles proven to reduce rehospitalizations. Implementation challenges including communication failures, caregiver engagement gaps, and resource constraints are addressed through implementation science approaches. Those aiming to improve the hospital discharge care transition should modify discharge processes to include community resource linkages and technology integration to achieve seamless transitions that improve patient safety and reduce rehospitalizations.