Many of the people in our care are trying to make a simple, safe and smooth transition from a healthcare facility like a hospital to their home.

Our non-medical care model includes services necessary to help patients transition safely out of a facility, including:

    • Coordinating communication between providers

    • Frequent follow-ups with families and discharge planners

    • Medication reminders

    • Transportation to doctor and allied-health appointments

    • Preparing meals

    • Running errands

    • Keeping homes clean and safe

What does the term “care transitions” mean?

The term “care transitions” refers to the movement of patients between healthcare practitioners and settings as their medical condition and care needs change during the course of a chronic or acute illness. It involves transitions between different care providers and settings, such as moving from a General Practitioner (GP) or specialist in an outpatient setting to a hospital physician and nursing team during an inpatient admission, and further transitioning to a skilled nursing facility or returning home with the assistance of a visiting nurse. Each shift from one care provider or setting to another is considered a care transition.

Why are hospitals interested in care transitions programs?

Hospitals are increasingly interested in care transitions programs due to healthcare reforms and initiatives aimed at reducing preventable readmission rates. The federal government emphasizes the importance of lowering readmission rates to save costs. Care transitions programs help hospitals focus on improving care coordination for patients across different settings, reducing the likelihood of related readmissions. These programs are relatively low-cost to implement and have the potential to yield positive clinical and financial outcomes, making them an attractive investment for hospitals.

What are some of the problems with the care continuum between healthcare settings?

The care continuum between healthcare settings often faces challenges due to the fragmented nature of the healthcare system. When patients move between settings, they often encounter fragmented care. Elderly patients with chronic illnesses or conditions may require care from multiple providers, leading to several issues:

    1. Misunderstanding or confusion among patients and their family caregivers about how and who should manage their care.

    2. Medication errors, including misunderstandings of instructions, medication adherence issues, and potential drug-drug interactions.

    3. Poor follow-up with General Practitioners (GPs) after discharge from a major procedure.

    4. Lack of knowledge about alternative care providers, such as home care services, in many communities.

How are care transitions initiatives addressing these issues?

Care transitions initiatives aim to address these challenges by empowering patients and their caregivers to actively participate in their care management. Programs educate patients and provide them with tools to manage their own care and navigate the transitions between settings. By enhancing patient education and self-management skills, they help reduce confusion and ensure better adherence to discharge instructions. Additionally, these initiatives focus on improving care coordination, reducing medication errors, promoting follow-up with GPs, and increasing awareness of alternative care providers.

Who are the key players in community-based transitions programs?

Community-based transitions programs involve multiple individuals across various settings to ensure a seamless transition across the care continuum. The key players typically include:

    1. Case Manager: A registered nurse responsible for patient assessment, treatment planning, health facilitation, and patient advocacy.

    2. Transition Coach: Usually a nurse or social worker designated by the program to prepare patients for each setting, equip them with knowledge and tools for self-management, and ensure a successful transition. They may be referred to by different titles, such as patient or care navigators, care intervention specialists, or transitions care coordinators.