Ti chiedevo maggiori dettagli per sapere se il paziente è affetto da una condizione cronica.
In ogni caso:

The Affordable Care Act of 2010 has put a spotlight on ensuring safe patient transfers between health care settings to prevent rehospitalization. Hospital readmissions are often influenced by a lack of outpatient transitional care programs to ensure the continuity of care during the transition from the inpatient setting to home.
Transitional care is defined as a time-limited,patient-oriented service, intended to ensure health care continuity, reduce risk of poor outcomes among at-risk populations, and facilitate safe and effective transfer between levels of care or healthcare settings.
http://scholarworks.umass.edu/cgi/viewcontent.cgi?article=10...

La definizione si applica anche nel caso di malati cronici:
the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing, has been at the forefront of research producing the evidence for a new way to assist and manage the health problems of the nation's elderly, particularly those with multiple health problems, as they move from hospital to home. This evidence-based model of transitional care has the potential of enhancing the quality of life for patients and their families, while also saving taxpayers millions of dollars annually.
http://www.nursing.upenn.edu/media/transitionalcare/Pages/de...

http://www.maimonidesmed.org/Main/ClinicalServices/SAFE-at-H...

http://www.researchgate.net/publication/15086338_Establishin...

Il concetto si applica anche ai malati cronici:
Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings.1, 2 High-quality transitional care is especially important for older adults with multiple chronic conditions and complex therapeutic regimens, as well as for their family caregivers.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2768550/