Care Across Settings: Challenges, Successes, and Opportunities

The 16 communities participating in the Aligning Forces for Quality (AF4Q) initiative are defining the obstacles to improving care transitions and designing initiatives to combat them. This brief examines several case studies from the AF4Q communities and the care-across-settings initiatives that they are undertaking. Their experiences demonstrate that the weakest link in a patient’s care is often the transition from one setting to another, but our health care system does not have consistent systems or funds in place for establishing care transitions programs.