SHM's Clinical Quick Talks-Transition of Care Lesson

Pdf Summary

Transition of care refers to the comprehensive planning and execution of moving patients from one healthcare setting to another or to their home based on their level of care. It is important to focus on transition of care because the current readmission rate within 30 days is 20%. This is often due to breakdowns in communication between the patient and providers, as well as between the hospital provider and the primary care physician. Patient education breakdowns and receiving conflicting information also contribute to this issue.<br /><br />An interdisciplinary approach with patient-centered care is necessary for effective transition of care planning. Social services, nurses, patients and their families, and healthcare providers including doctors, nurse practitioners, and physician assistants in the hospital, as well as the primary care physician, should be involved in this process.<br /><br />When patients are being transitioned from the hospital to other healthcare settings or home, certain information should be included at discharge. This includes the reason for hospitalization, tests and treatments provided during the hospital stay, instructions for what to do upon discharge, medications (new, continued home medications, and discontinued medications), signs and symptoms to monitor for and what to do when they occur, follow-up instructions with the primary care physician and specialists as needed, and follow-up testing as appropriate.<br /><br />One model for transition of care is the Better Outcomes by Optimizing Safe Transitions (BOOST) program developed by the Society of Hospital Medicine. It is important to implement strategies such as using teach-back methods to ensure patient understanding, involving families and caregivers in the discharge process, and keeping the information simple, especially for complex patients with multiple co-morbidities.<br /><br />In conclusion, effective transition of care is crucial to reduce readmission rates. It requires a collaborative approach involving various healthcare professionals and careful inclusion of necessary information at discharge.

Asset Subtitle

Himabindu Lanka

Keywords

Transition of care

Readmission rate

Breakdowns in communication

Patient education

Interdisciplinary approach

Discharge information

Medications

Follow-up instructions

BOOST program

Collaborative approach