Which practice is a key component of a transition of care program for high-risk patients?

• A. Reducing follow-up after discharge.
• B. Isolating patients from the system.
• C. Increasing medication changes.
• D. Dedicated resources for safe transitions, close monitoring, and reduced readmissions.

Answer: (D)

Effective transition of care for high-risk patients relies on dedicated resources that coordinate across care settings to ensure safe handoffs, close monitoring, and efforts to reduce readmissions. When teams have focused programs, they implement medication reconciliation, timely follow-up appointments, patient and caregiver education, and clear communication among hospital, primary care, and community supports. This structured support helps catch issues early, prevents gaps in care, and keeps patients safely connected to the right services after discharge.

Reducing follow-up undermines monitoring and swift response to problems; isolating patients from the system breaks continuity of care; and increasing medication changes without a coordinated plan can introduce confusion and errors.