Transitional care

The term "care transitions" refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

1. TRANSITIONAL CARE DR.VINOLI.S.G Professor HOD Medical Surgical Nursing Dept Universal College Of Nursing Bangalore

2. INTRODUCTION Transitional care is a broad term that encompasses a variety of intermediate care services, including sub acute, skilled, and rehabilitative care services. Transitional care bridges the gap between hospital and home for patients with complex or multiple problems. 10/6/2020 2 Dr.Vinoli.S.G

3. MEANING Meaning of "Care Transitions" The term "care transitions" refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. 10/6/2020 3 Dr.Vinoli.S.G

4. DEFINITION Transitional care or care transition is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, sub-acute and post-acute nursing facilities, the patient's home, primary and specialty care offices, and long-term care facilities - American Geriatrics Society 10/6/2020 4 Dr.Vinoli.S.G

5. Need of Transitional care in ICU Critically ill patients in the intensive care unit often experience a lot of changes as they move through different levels of care. 10/6/2020 5 Dr.Vinoli.S.G

6. ELEMENTS OF TRANSITIONS OF CARE Communication Changes in plan of care Medication reconciliation Follow-up tests and services Education of the patient and family Transfer of all information when site of care changes Involvement of team during hospitalization, discharge, follow-up, etc. 10/6/2020 6 Dr.Vinoli.S.G

7. TRANSITIONAL CARE MODEL 10/6/2020 7 Dr.Vinoli.S.G

8. Uses of care transitions intervention Patients who received this program were: Significantly less likely to be readmitted. More likely to achieve self-identified personal goals around symptom management and functional recovery. 10/6/2020 8 Dr.Vinoli.S.G

9. BARRIERS TO SUCCESSFUL TRANSITIONS Barriers to effective care transitions at three levels: The  Delivery System The lack of formal relationships between care settings represents Lack of financial incentives promoting transitional care The lack of information systems designed to facilitate the timely transfer of essential information. The Clinician Nursing staff shortages Clinicians do not verbally communicate patient information to one another across care settings. 10/6/2020 9 Dr.Vinoli.S.G

10. The Patient Barriers Lack of advocacy or outcry from patients for improving transitional care until they or a family member is confronted with the problem firsthand. Older patients and their caregivers often are not well prepared or equipped to optimize the care they will receive in the next setting. They may have unrealistic expectations about the content or duration of the next phase of care and may not feel empowered to express their preferences or provide input for their care plan. Patients may not feel comfortable expressing their concern that the primary factor that led to their disease exacerbation was not adequately addressed. 10/6/2020 10 Dr.Vinoli.S.G

11. KEY COMPONENTS OF SUCCESSFUL TRANSITIONS Focus on Patient and Caregiver Understanding Helping Patients Manage Health Issues and Prevent Decline Medication Reconciliation and Management Transitional Care, Not Ongoing Case Management 10/6/2020 11 Dr.Vinoli.S.G

12. Role of Transitional Care Nurse The TCN role is very different from a traditional nursing position. It incorporates the skills of a nurse, care manager, and patient advocate and knowledge of evidence-based care, managing complexity, palliative care, active engagement of family caregivers, interdisciplinary team care, theories and strategies for individualized care and behavioral change, quality improvement, and organization, delivery and financing of services across an episode of acute care. 10/6/2020 12 Dr.Vinoli.S.G

13. Healthcare transitions ensure safe and efficient movements of patients between different sectors of care within the healthcare system. Transition as a concept is central to the nursing discipline as a whole. Nurses often are the primary health professionals involved in encounters with patients and their families that relate to transitional periods of instability. 10/6/2020 13 Dr.Vinoli.S.G

14. CONCLUSIONS 10/6/2020 14 Dr.Vinoli.S.G

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