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Learn MoreThis blog post is based on a HealthStream article, The Transition of Care Across the Continuum: Optimizing Care for Older Adults.
After being released from the hospital, one of five Medicare beneficiaries will be readmitted within 30 days. It has been estimated that this pattern of recurrence comes at a cost of $2.6 billion annually; as many as 75% of these readmissions could possibly be avoided. Poor transitions of care are an important part of the problem.
Defining Frailty
An important first step in determining the care plan for an older patient is to assess whether the patient is frail, which can have a serious impact. According to Dr. Eleanor McConnell, director of the Centers for Excellence in Geriatric Nursing Education at Duke University, “Frailty increases the risk of falls and fractures, disability, hospitalization, complications after surgery, and even death. Determining frailty early in a hospitalization helps clinicians address the root causes of falls, disabilities, or complications, and allows them to make better plans for post-hospital care,” says McConnell. “Frailty, in combination with other risk factors, increases an older patient’s vulnerability to a difficult transition of care and re-hospitalization.”
Care Transitions and Vulnerability
In addition to frailty, says McConnell, “Older patients are more vulnerable during transitions of care because they may have poor health literacy, decreased social support, functional impairment, and or medical problems, such as coexisting chronic medical problems.”
Study participants saw a need to increase the care team’s confidence about speaking up at the time of discharge regarding concerns they may have. The module seeks to improve team knowledge and provide caregivers with the tools they need to achieve a more effective transition of care.
The National Transition of Care Coalition has defined seven intervention categories. Patient-and family-focused interventions include medication management, transition care planning, and patient and family engagement and education. Provider-focused interventions include information transfer, follow-up care, healthcare provider engagement, and shared accountability across organizations.
A Shared Framework for Caregivers
Inter-professional cooperation while caring for older adults is essential. “While care providers should rely on their experience and expertise, they should also operate within a shared framework that includes understanding the patient’s values and preferences, relying on best practices and available evidence, and setting realistic goals of care with the patient and family,” says Dr. Mitchell Heflin, associate professor of medicine at the Duke School of Medicine and senior fellow in the Center for the Study of Aging and Human Development.
“All team members should be encouraged to engage the patient by listening and questioning. It’s also important to tap into the capabilities of every team member,” says Heflin. “A few simple questions from the CNA, for example, can lead to a very important exchange, with the patient revealing important information about his or her concerns. If the CNA is empowered to speak up to the rest of the team, this will inform decision-making about the patient’s transition of care. Listening to the patient helps the team develop a care plan that addresses the patient’s goals and preferences,” Heflin explains.
“A point person should be designated, typically one of the practitioners, to guide the interprofessional team and coordinate the transition appropriately. This point person can help formalize transition planning tools, including a transition summary, and make sure the plan is focused on the patient’s needs,” adds Heflin.
Module Now Online
HealthStream’s acute care Transitions of Care module is online now, with modules addressing other settings to follow. Each starts with a confidence survey and ends with a knowledge assessment. Upon successful completion, the participant receives an inter-professional frail elder care certificate, awarded from Duke Health.
HealthStream’s learning management system and comprehensive suite of competency management tools empower your healthcare workforce to deliver the best patient care.
View All Learning & PerformanceHealthStream offers performance learning management solutions to help develop your healthcare staff into leaders and reduce turnover.
View All ProductsHealthStream works with healthcare organizations to create engaging and high-quality training videos for your staff and management.
View All ProductsImprove care quality and save money by making informed decisions about your healthcare facility and staff with HealthStream's reporting analytics solution.
View All ProductsHealthStream's proven methods for the improvement and overall engagement of your healthcare staff foster a positive workplace and increase retention rates.
View All ProductsThe leadership development program from HealthStream helps mold your high-potential healthcare employees into proven leaders.
View All ProductsWhen you enact HealthStream's quality compliance solutions, you can do so with the confidence your healthcare organization will meet all standards of care.
View All Quality & ComplianceFulfill compliance requirements with a variety of programs and courseware designed to address critical regulatory requirements as well as educate staff to recognize and mitigate risks.
View All ProductsBy increasing your healthcare staff's focus on quality and safety with HealthStream, they can help to reduce medical errors and readmission rates.
View All ProductsLearn about what HealthStream's healthcare policy management software and how it can help aid your organization efforts.
View All ProductsHealthStream's education helps address diversity, equity, and inclusion within your organization, as well as promoting health equity in the communities you serve.
View All ProductsHealthStream offers professional training and education on how to best optimize your reimbursement process within your healthcare organization.
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View All ProductsLearn about our advanced resuscitation training solutions. Our solutions are designed to help improve patient outcomes.
View All ResuscitationIn all areas of resuscitation, from neonatal to elderly care, clinical deterioration is a risk that can be avoided with the help of HealthStream's training programs.
View All ProductsHealthStream's EMS Program offers a comprehensive, CAPCE accredited EMS course library that meets National Registry annual recertification.
View All ProductsNurture the skills of your nurses and medical staff to help mold them into effective leaders with development training from HealthStream.
View All ProductsExpand the decision-making skills and effectiveness of your healthcare workforce with HealthStream's clinical development programs and services.
View All Clinical DevelopmentMake sure your clinicians have the support they need to provide competent care with clinical competency training and development from HealthStream.
View All ProductsHealthStream’s learning management system and comprehensive suite of competency management tools empower your healthcare workforce to deliver the best patient care.
View All ProductsThe suite of healthcare onboarding solutions available from HealthStream aids in nurse retention and improved patient outcomes.
View All ProductsGive your healthcare staff the decision support and skills training they need with the online products available from HealthStream.
View All ProductsHealthStream leverages medical professional development in healthcare by providing staff training programs
View All ProductsLearn more about HealthStream's Provider Credentialing, privileging, & enrollment solutions.
View All CredentialingExperience standardized and centralized healthcare credentialing, privileging, and enrollment that is smarter and faster than ever before.
View All ProductsAutomated, web-based provider credentialing and enrollment software for growing medical groups.
View All ProductsNCQA-certified CVO verification services for initial and re-credentialing files in an overflow or full-service capacity for healthcare organizations.
View All ProductsSearch, review, and add providers into the Epic provider master file with our Epic app integration, Provider Validate.
View All ProductsMake sure your healthcare staff can schedule out appointments and work schedules with ease using HealthStream's line of software solutions.
View All SchedulingHealthcare scheduling software designed to optimize staffing requirements & elevate patient care
View All ProductsPrecisely align staffing and needed resources to enable efficient patient flow and high-quality, cost-effective patient care.
View All ProductsHealthStream’s free nurse schedule app, NurseGrid™, is built to help you care for your staff and engage with their specific needs.
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