Transitional care plays an important role for anyone ending a hospital stay and headed for further recovery in the home or other care facility. According to an article in the American Journal of Nursing, this area of 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. 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” (Naylor & Keating, 2009).
The Agency for Healthcare Research and Quality (AHRQ) shares that care transitions “increase the risk of adverse events due to the potential for miscommunication” as responsibility for care continuity is given to new parties. One reason is that every hospital discharge is a complex process representing a time of significant inherent vulnerability for patients. Safe and effective transfer of responsibility for a patient’s medical care relies on effective provider communication with patient comprehension of discharge instructions.
The National Transitions of Care Coalition identifies seven opportunities to use communication as a tool for improved transitional care. Here they are with some of their component activities that make up a better transitional care model:
Ensure safe use of medications through education of the patient, family and caregivers. Some ways to do this involve:
Facilitate the move from one level care to another, guided by an experienced transition practitioner who is part of the healthcare team. Components include:
Education and counseling of patients and families works to enhance their active participation in their own care including informed decision making. Features include:
Share important care information among patient, family, caregiver and healthcare providers in a timely and effective manner. Recommendations include:
Ensure that Patients and families get timely access to key healthcare providers after an episode of care as required by the patient’s condition and needs. Strategies include:
The appropriate provider should demonstrate ownership, responsibility, and accountability for the care of the patient and family/caregiver at all times. Activities include:
It is possible to enhance the transition of care process through securing accountability for care of the patient by both the healthcare provider (or organization) transitioning and the one receiving the patient. This involves:
Improving transitional care is one of the ways healthcare organizations can work to avoid unnecessary readmissions, which drive up the cost of healthcare. Organizations across the care continuum are paying lots of attention to improving care transitions, especially now that higher acuity patients in recovery and rehabilitation are commonly being found outside of hospitals. Learn about HealthStream’s solutions for workforce development across the continuum of care.
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