Why Do Care Transitions Remain a Black Hole in Healthcare?

Care transitions between acute and post-acute care remain highly inefficient, manual, and error-prone, even with EHRs. A case manager spends nearly half their time on non-essential clerical tasks, impacting patient experience and safety. Manual processes, including faxing outdated or incomplete records, increase the risk of errors, especially with medications. Prolonged transitions lead to avoidable patient days, which add financial strain and reduce hospital bed availability. Contributing factors include fragmented healthcare systems, lack of standardized data exchange, and historical tolerance for readmissions. Payers, incentivized by lower costs and healthier patient outcomes, could support electronic tools for efficient communication and accurate information exchange across care settings.