Transitional Care | GT Independence

If you’re in and out of the hospital on a regular basis, you know about transitional care. But do you know how to make the process a more positive experience with a decreased likelihood of rehospitalization? The Transitional Care Model can help.

What Is Transitional Care?

Transitional care refers to the coordination and continuity of health care during a movement from one healthcare setting to another or to home. This care is traditionally provided as needs change over the course of a chronic or acute illness.

The American Geriatric Society¹ completed an extensive study on the re-hospitalization rates of those who receive transitional care. Those who went through a transition in care types were 40% more likely to experience a preventable hospitalization and 58% more likely to experience any type of hospitalization than those who remained under care in their home.

Main Contributors to Gaps in Care

Older adults and disabled individuals with multiple chronic conditions are particularly vulnerable to breakdowns in care during the transition process. The following things are the main contributors to gaps in care:

Poor communication
Incomplete transfer of information
Inadequate education of caregiver
Inadequate education of patient
Limited access to essential services
Absence of single point person in charge of continuity of care
Existing standards which focus only on outcomes within settings

According to the Journal of the American Geriatrics Society², interventions such as discharge planning process, coaching patients, and home visits by an advance practice nurse can reduce re-hospitalization. Of those studied, 22% of individuals who had a physician follow-up visit were readmitted, compared to 52% of those without a follow-up visit.

In order to combat these common contributors, the Transitional Care Model has been created to address the negative effects and prepare patients and caregivers to manage changes in health. This model can help to decrease the likelihood of re-hospitalization along with improving health outcomes after hospital discharge and increasing your satisfaction with the care process.

10 Essential Elements for Smooth Transitional Care

1. A Skilled Transitional Care Nurse

A skilled and knowledgeable transitional care nurse can deliver and coordinate care of high risk patients across all healthcare settings. The transitional care nurse is the primary coordinator of care throughout the care transition process and ensures continuity.

2. Care Assessment

The best care is tailored to the patient’s needs. Good transitional care includes a comprehensive assessment of the patient’s needs, goals, and preferences.

3. Collaboration

The patient, caregivers, and team members must work together to create and implement a streamlined care plan.

4. Home Visits

Transitional care takes time. Regular home visits by the transitional care nurse with ongoing telephone support can help keep the care plan on schedule.

5. Care Continuity

When a patient is transferred between different hospitals or care providers, it can be easy to lose information. The transitional care nurse keeps makes sure care stays continuous and information isn’t lost during changes or transfers.

6. Goal Based

Traditional care includes the active engagement of patient and caregivers, with a focus on meeting their goals.

7. Ahead of the Game

Transitional care emphasizes the patient’s early identification and response to health care concerns.

8. Multidisciplinary

With transitional care, the patient is not alone. Instead, it approaches care in a way that includes the patient, caregivers, and healthcare professionals as team members.

9. Communication

Transitional care focuses on strong collaboration and excellent communication between the patient, caregivers, and healthcare team. This includes episodes of acute care and planning for future transitions.

10. Ongoing Support

Transitional care is all about planning for change and transition, so a huge focus is on ongoing monitoring to improve care.

Get Support From People You Know and Trust

If you have a regular caregiver and healthcare professionals, discuss this model as your preferred method of transitional care before it is needed. Alternatively, ask your healthcare professionals what their model of transitional care looks like and compare it to this model. It can also be helpful to have a family member involved in the process to keep notes make sure your care team is on the same page when it comes to your transitional care.

For those transitioning to home and community based care, the Journal of the American Geriatrics Society¹ explains that it is especially important to maintain a consistent set of providers who are familiar with your medical needs and have high accessibility. These individuals should be focused on ways to improve the transition and ease into the changes that come along with transition.

According to the American Geriatric Society¹, transition programs should not end at the time of transition. Counseling or case management throughout the process and frequent follow-ups could help to address problems or unmet needs before they lead to more intensive care needs or to decline.

No matter what transitional care model is used, be sure to stay involved in the care process and educated about your care.

Resources

¹Wysocki, A., Kane, R.L., Dowd, B., Golberstein, E., Lum, T., & Shippee, T. (2014). Hospitalization of elderly medicaid long-term care users who transition from nursing homes. Journal of the American Geriatrics Society, 62(1), 71-78.

²Yin, C. Y., Barnato, A. E., & Degenholtz, H. B. (2011). Physician follow-up visits after acute care hospitalization for elderly medicare beneficiaries discharged to noninstitutional settings. Journal of the American Geriatrics Society, 59(10), 1947-1954.