• care transitions;
  • older adults;
  • qualitative study;
  • clinician roles;
  • healthcare professionals


To identify the perceived roles and responsibilities of clinicians during care transitions of older adults.


Qualitative study involving 1-hour in-depth semistructured interviews. Audiotapes of interviews were transcribed, coded, and analyzed, and themes and subthemes were generated.


An acute care hospital, a skilled nursing facility, two community-based outpatient practices, and one home healthcare agency.


Forty healthcare professionals directly involved in care transitions of older adults (18 physicians, 11 home healthcare administrative and field staff, four social workers, three nurse practitioners, three physician assistants, and one hospital case manager).


Perspectives of healthcare professionals regarding clinicians' roles and responsibilities during care transitions were examined and described.


Content analysis revealed several themes: components of clinicians' roles during care transitions; congruence between self- and others' perceived ideal roles but incongruence between ideal and routine roles; ambiguity in accountability in the postdischarge period; factors prompting clinicians to act closer to ideal roles; and barriers to performing ideal roles. A conceptual framework was created to summarize clinicians' roles during care transitions.


This study reports differences between what healthcare professionals perceive as ideal roles of clinicians during care transitions and what clinicians actually do routinely. Certain patient and clinician factors prompt clinicians to act closer to the ideal roles. Multiple barriers interfere with consistent practice of ideal roles. Future investigations could evaluate interventions targeting various components of the conceptual framework and relevant outcomes.