It’s during that critical time when problems can occur. Patients may get sicker because they don’t have access to medications, transportation, food or crucial equipment such as oxygen tanks. And many don’t have relatives or caregivers to help with the daily tasks that they were able to perform unassisted before being hospitalized.
“There are gaps in care, there are gaps in communication, there are gaps in adequate preparation for patients and families,” said Mary Naylor, who designed a transitions model to address these problems.
