Transition of Care
As patients transition from one level of care to another, there is a high probability that a communication error can occur. It is especially important when transferring a patient from one facility to another.
The transition of care can be within settings such as from ICU to a step-down unit, between settings such as from a hospital to home health, across health states such as curative care to hospice, and between providers. The transition of care requires continuity and coordination between the sending and receiving caregivers. There should be a comprehensive plan of care and healthcare professionals at the receiving location, which have the skills, experience, and equipment and supplies to care adequately for the patient. Logistical arrangements to get the patient to their new care facility/area and education of the patient and family about the move must also be included in the planning for the move (NTOCC, n.d.).
Seven Essential Intervention Categories for Patient Transition to Another Facility Seven Essential Intervention Categories for Patient Transition to Another Facility
- Medication management
- Transition planning
3.Patient and family engagement and education - Information transfer
- Follow-up care
- Healthcare provider engagement
- Shared accountability across providers and organizations
Medication Management in the Transition of Care
Medication management is a crucial aspect of patient care and plays a significant role in the transition of care. Transition of care refers to the transfer of a patient from one healthcare setting to another, such as from a hospital to a nursing home, or from a doctor’s office to a home setting. During this transfer, it is important to ensure that the patient’s medications are managed correctly to prevent adverse drug events and ensure continuity of care.
One of the challenges in medication management during the transition of care is ensuring that the patient’s medication list is up-to-date and accurate. This requires collaboration between healthcare providers, who must communicate effectively and share important information about the patient’s medications. To ensure that patients receive the right medications at the right time, it is essential to have a complete and accurate medication list. This list should include all prescription and over-the-counter medications, as well as any vitamins or supplements that the patient is taking.
Another challenge in medication management during the transition of care is avoiding medication errors, such as prescribing a medication that the patient is allergic to, or giving a medication at the wrong time or dose. To minimize these errors, healthcare providers should follow established protocols for verifying and reconciling medication lists during the transition of care. They should also educate patients and their families about their medications, including the purpose of each medication, the proper way to take it, and any potential side effects.
In addition to avoiding medication errors, medication management during the transition of care also involves ensuring that patients have access to their medications after they leave the hospital. This may involve coordinating with pharmacists, who can help patients obtain the medications they need and answer any questions they may have. Patients should also be educated about the importance of taking their medications as prescribed and informed about any changes to their medication regimen during the transition of care.
Finally, medication management during the transition of care requires ongoing monitoring and assessment to ensure that the patient is responding to their medications as expected. Healthcare providers should regularly evaluate the patient’s response to their medications and adjust their regimen as needed to ensure optimal treatment outcomes.
In conclusion, effective medication management is crucial during the transition of care to ensure that patients receive the right medications at the right time, prevent adverse drug events, and ensure continuity of care. Healthcare providers must work collaboratively to ensure that patients receive the best possible care and that their medications are managed effectively during the transition of care.
Transition planning
Transition planning is a crucial component of transition of care, as it helps to ensure that patients receive seamless, coordinated, and effective care as they move from one healthcare setting to another. This can involve transitions from hospital to home, hospital to rehabilitation center, or from one healthcare provider to another.
The transition of care process can be complex and often involves multiple healthcare providers, facilities, and community resources. Effective transition planning helps to minimize gaps in care, reduce the risk of adverse events, and improve patient outcomes. It also helps to ensure that patients receive the appropriate level of care and support as they move through the healthcare system.
Transition planning is a crucial component of transition of care, as it helps to ensure that patients receive seamless, coordinated, and effective care as they move from one healthcare setting to another. This can involve transitions from hospital to home, hospital to rehabilitation center, or from one healthcare provider to another.
The transition of care process can be complex and often involves multiple healthcare providers, facilities, and community resources. Effective transition planning helps to minimize gaps in care, reduce the risk of adverse events, and improve patient outcomes. It also helps to ensure that patients receive the appropriate level of care and support as they move through the healthcare system.
To effectively plan for transition of care, healthcare providers should start by gathering information about the patient’s health status, medical history, and current medications. They should also assess the patient’s physical, cognitive, and emotional needs, as well as any social or community support systems. This information should be shared among all healthcare providers involved in the patient’s care, to ensure that everyone is on the same page and working towards the same goals.
Next, a comprehensive care plan should be developed, which outlines the steps and resources needed to support the patient’s transition to the next healthcare setting. This may include medical treatments, therapies, medications, and other healthcare services. It should also identify any potential barriers to the transition and strategies to overcome them.
To ensure effective communication and coordination during the transition of care, healthcare providers should establish clear lines of communication and regular check-ins with each other. This can include phone calls, email, or in-person meetings, and should be documented in the patient’s medical record.
Patient and family engagement and education
Patient and family engagement and education in transition of care is a critical aspect of ensuring a safe and effective healthcare experience. The transition of care refers to the movement of a patient from one care setting to another, such as from the hospital to a rehabilitation center or from a doctor’s office to the patient’s home. The process can be complex and often involves multiple healthcare providers, making it essential for patients and their families to be informed and involved in the process.
Patient engagement is the active involvement of patients and families in their own care. This includes sharing information about their health status, goals, and preferences, as well as making decisions about their treatment options. Patient engagement has been shown to improve the quality of care, reduce healthcare costs, and enhance patient satisfaction.
Family education is another important component of transition of care. It involves providing families with information about the patient’s condition, treatment options, and what to expect during the transition process. This can help families to better understand their loved one’s health status, and also prepare them for the responsibilities they may face in caring for the patient at home.
Effective patient and family engagement and education requires collaboration between healthcare providers and patients and their families. Providers should take the time to explain medical conditions, treatments, and procedures in language that is easy to understand, and to provide clear instructions for managing medications and monitoring the patient’s health status at home. Patients and families should be encouraged to ask questions and voice their concerns, and providers should be responsive to their needs.
In addition to improving patient outcomes, patient and family engagement and education can also help to reduce readmissions, prevent adverse events, and improve patient satisfaction. Patients who are informed and involved in their care are more likely to adhere to their treatment plan and have a better understanding of their health status, which can lead to improved outcomes.
Information transfer
Inadequate information transfer during transition of care can lead to a number of adverse outcomes, including medical errors, duplicated tests and treatments, and decreased patient satisfaction. To address these challenges, it is important to implement effective strategies and technologies to facilitate information transfer during transitions of care.
One effective strategy is the use of electronic health records (EHRs). EHRs can provide a centralized repository of patient information that is accessible by all healthcare providers involved in a patient’s care. This can help ensure that the most up-to-date information about a patient is available at each transition of care and can also help reduce the risk of medical errors.
Another strategy is the use of care transitions teams. These teams can help coordinate the transfer of information between healthcare providers and organizations, as well as help ensure that patients receive the appropriate follow-up care and support after their transition. Care transitions teams can include a variety of healthcare professionals, such as nurses, social workers, and pharmacists, and can help bridge the gap between different healthcare settings.
Effective communication between healthcare providers is also essential for ensuring the successful transfer of information during transitions of care. This can be accomplished through regular communication and collaboration between providers, as well as through the use of structured handoff processes that provide clear and concise information about a patient’s care and status.
The transition of care process can be challenging for patients, particularly if they are moving from a hospital setting to a home or community-based setting. During this time, patients may experience a range of physical, emotional, and practical issues, and it is important that they receive the necessary support to manage these challenges. Follow-up care plays a critical role in ensuring that patients receive the necessary care and support during this time.
One of the key benefits of follow-up care is that it helps to ensure that patients receive timely access to care and support. This can be particularly important for patients with chronic conditions, who may require ongoing care and support to manage their health. By scheduling regular follow-up appointments, healthcare providers can monitor the patient’s progress and make any necessary changes to their care plan.
Follow-up care also helps to improve communication between healthcare providers and patients. This can be particularly important in the transition of care process, as it allows healthcare providers to provide patients with information and support to help them manage any challenges they may be facing. This improved communication can also help to address any concerns or questions the patient may have, and ensure that they receive the necessary support to manage their health and wellbeing.
Effective follow-up care also helps to reduce the risk of readmissions to the hospital. By providing patients with the necessary care and support, healthcare providers can help to prevent any complications that may arise during the transition of care process. This can help to ensure that patients receive the necessary care and support to manage their health, and reduce the risk of hospital readmissions.
Population health has been difficult to define, but the general consensus of all the definitions includes the aspects of: health outcomes of a group of individuals; increasing healthier lifestyles of individuals in the group, collaboration of healthcare systems, communities, public health services, employers, schools, and the inclusion of health status indicators in addition to measurements of social, economic, and physical environments, and personal health practices (Stoto, 2013).
Learning what healthcare customers value helps organizations to tailor programs and services to meet the needs of their communities. There is a much greater emphasis on neighborhood health by accreditation agencies now and on the expanded role which healthcare organizations play in education, support, and planning outside of their four walls. Organizations must adapt to this challenge by being creative, partnering with others, and keeping their figurative finger on the pulse of their community. Focus groups, disease specific support groups, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey results, and community health fairs are just some examples of sources for consumer input.
The Affordable Care Act added a new Internal Revenue Service (IRS) requirement for healthcare entities and public health systems (Stoto, 2013). Hospitals must conduct a Community Health Needs Assessment (CHNA) every three years. The assessment must describe the community served, identify existing health care resources, and prioritize the health needs of the community. Once this is completed, the hospital must develop and implement an action plan to meet the needs identified within the community.
The Public Health Accreditation Board (PHAB) requires health departments to participate in or conduct a collaborative process with others in the community (Stato, 2013). The health departments must conduct a planning process and develop/implement a community health improvement plan, which has a performance measurement system to monitor the achievement of the objectives of the improvement plan.
The Institute for Healthcare Improvement (IHI) has encouraged implementation of their Triple Aim which addresses health of a population, the quality of care, and the per capita cost (Feeley, 2014). Feeley states that to have a high impact in population health, leadership is going to have to change their leadership behaviors and become person centered, have front line engagement, relentless focus, transparency, and be without boundaries.
The Institute of Medicine (IOM) conducted a study, commissioned by the Robert Wood Johnson Foundation, to examine the measurement, laws and funding that influence the health of the public (IOM-Public Health, 2010). The committee suggested that changes need to be made in the processes, tool, and approaches used to gather information concerning health outcomes and failure to achieve the desired outcomes. The IOM stated that there must be measurement of the environmental failures, such as a lack of healthy food, adequate housing, and transportation issues. The report further calls upon the Health and Human Services department to develop a standardized set of measurements that address health outcomes and indicators of community health, as well as a single, broad measuring tool for public health. This standardization of measures and tools would enable comparison of data across geographic and other areas with an apple to apple comparison.
There are already several initiatives that are aimed at improving population health. The IHI has campaigned to improve health through their 5 Million Lives initiative and now with their Triple Aim initiative. Another community initiative is the Healthy People 2020 initiative of the Office of Disease Prevention and Health Promotion (ODPHP) within the U.S. Department of Health and Human Services (HHS). Aimed at disease prevention, Healthy People 2020 is a United States’ initiative to promote community health. Healthy People 2020 provide science-based, 10-year national objectives for improving the health of all Americans (Healthy People, n.d.).
The Healthy People Consortium is a diverse, motivated group of agencies and organizations nationwide that are committed to achieving Healthy People 2020 goals and objectives. Consortium
partners represent a wide range of agencies and organizations including community groups, private businesses, national membership groups, colleges and universities and religious organizations. Membership in the consortium is open to any agency or organization that supports Healthy People 2020 goals and objectives (Healthy People, n.d.). The Healthy People 2020 website has information on the 26 indicators they are tracking and an updated status report on their accomplishments to this point in time. There are also tools, resources, and other information that may be helpful in this initiative for healthy populations.
Another resource is the Centers for Disease Control and Prevention (CDC). The CDC Division for Population Health has a website with information concerning their programs for various populations including wellness and disease programs (CDC – Population Health, 2015). This site also contains publications and reports that may be useful to an organization’s population health initiatives.
