TRANSITION OF CARE

INTRODUCTION

The patient’s journey through the health care system can involve a number of interfaces
between primary, community and hospital care. The constant in these transitions is the
patient, and their families and carers. Thus, it is imperative that the patient’s role and
responsibilities are considered central to any strategies that support safe and effective
transitions of care. Transitions of care are an integral part of patient care, and it requires
sufficient resources to ensure effective care transition and coordination.

DEFINITION

Transitions of care is 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 hospitals, sub-acute and post-acute
nursing facilities, the patient’s home, primary and specialty care offices, and long-term care
facilities.

POINTS OF TRANSITION

1. Within settings: Primary care to specialty care, or intensive care unit (ICU) to ward.
2. Between settings: Hospital to sub-acute care, or ambulatory clinic to senior centre.
3. Across health states: Curative care to palliative care or hospice, or personal residence
to assisted living
4. Between providers: Generalist to a specialist practitioner, or acute care provider to a
palliative care specialist

CATEGORIES OF TRANSITIONS
A) Transitions between entities of health care system

 Among members of one care team (receptionist, nurse, physician)

  Between patient care teams
  Across settings (primary care, specialty care, inpatient, emergency department)
  Between health care organizations

B) Transitions over time.

  Follow-up visit
 Across lifespan paediatric developmental stages, women‘s changing
 Reproductive cycle, geriatric care needs
 Across trajectory of illness and changing levels of coordination need

KEY ATTRIBUTES OF TRANSITION

1. CRITICAL POINTS AND EVENTS IN LIFE

Within the context of an intensive care unit, majority of patients are admitted here because
of an urgent medical situation, needing high-level medical support of vital functions to keep
the patient alive. Patient and their families may initially experience emotional distress due to
the complicated life-supporting and monitoring devices and background noises encountered
in intensive care units. Experiencing critical illness and requiring admission to an ICU can be
extremely frightening and traumatic, causing distress and disorder in the life of the individual
involved and their relatives. Treatment within an intensive care unit is stressful for patients
and can cause long term physical and psychological problems. Patients being considered for
transfer from ICU to the acute medical ward have very complex health situations and
multiple comorbidities

2. INSTABILITY AND UN-ANTICIPATED CHANGES

The patients’ underlying pathology and physiological changes may be treated and managed
until their condition stabilises or they recover they are transitioning from high technological
units to less acute environments, and many interprofessional providers are involved in
exchanges of information and responsibility. Patients transferring from an intensive care unit
to a general ward are particularly vulnerable to preventable harm due to the high volume of
complex information to be communicated toward staff and the transition to reduced
monitoring. Transitions in patient care are characterized by the movement of people and
information between healthcare providers and care settings. These changes in environment,
care, relationships, information and independence place patients and their families at risk of
transfer anxiety or relocation stress.

3. MULTIPLE FACTOR AND MULTIPLE NEEDS

Family caregivers need information and skills to help deal with patients’ care needs, pace
between expectations and reality, and practice better self-care. Because of the unique
challenges faced during each stage, patient and family needs vary significantly throughout
their trajectory. Each transition is unique to the patient and is influenced by patient’s and
family’s past experiences as well as present situation and interventions. Multiple factors
include adverse effects of medication, insufficient follow-up, premature discharge, limited
support after discharge, and inadequate communication from te concerned staff.

4. INADEQUATE CONTINUITY OF CARE

Recently, professional caregivers in health-related fields have become aware of major issues
in the quality of people’s lives and continuity of care post discharge from intensive care unit[.
The failure to have continuity of care during multiple transitions can lead to medical errors,
miscommunication, and care that conflicts with the wishes of the patient and family. Care
providers can facilitate transitions and the continuity of care by providing guidance and
ensuring that the right level of care is provided. Promoting continuity of care and preventing
complications during recovery from acute illness requires that patient follow up and
assessments continue beyond the acute phase of an illness .

5. POOR COORDINATION OF CARE AND COMMUNICATION AMONG

HEALTH CARE PROVIDERS, PATIENTS AND FAMILIES

When a patient transitions from the hospital setting to another health care setting,
coordination and communication among providers and patients is crucial to preventing
adverse outcomes. Contributing factors include breakdown in communication, suboptimal
handover processes and the lack of appropriate knowledge and skills of ward staff. Poor
communication with family can have disastrous effects on the transition.. Miscommunication
within the interdisciplinary team often leads to unrealistic expectations on the part of the
family, which creates conflicts between the family and the members of the various treating
teams.

6. AWARENESS
Awareness is related to knowledge, perception and recognition of a transition experience that
influences the individual's response. Information to be provided regarding the patient’s
progress and prognosis.

7. ENGAGEMENT

Level of awareness and conditions of patient's individual situation (beliefs, attitudes,

socioeconomic status, readiness and knowledge), and environmental
situations(communication status and community support) affect the level of participation in
the transition

8. ADAPTATION

A process that dynamically occurs over time which include feeling connected, allowed to
interact and interacting, being situated, developing confidence and coping.

ROOT CAUSES OF INEFFECTIVE TRANSITIONS OF CARE

Many factors contribute to ineffective transitions of patient care, and these root causes often
differ from one health care organization to another.

1. Communication breakdowns. Care providers do not effectively or completely

communicate important information among themselves, to the patient, or to those taking
care of the patient at home in a timely fashion.

2. Patient education breakdowns. Patients or family/friend caregivers sometimes receive

conflicting recommendations, confusing medication regimens, and unclear instructions
about follow-up care. Patients may lack a sufficient understanding of the medical

condition or the plan or care. As a result, they do not buy into the importance of
following the care plan, or lack the knowledge or skills to do so.
3. Accountability breakdowns. In many cases, there is no physician or clinical entity that
takes responsibility to assure that the patient’s health care is coordinated across various

settings and among different providers.

MEASURES TO ENSURE SAFE TRANSITION:

1. Multidisciplinary communication, collaboration and coordination :

A care team – including a physician, nurse, pharmacist, social worker, and others as

appropriate – communicates, collaborates and coordinates effectively. The team begins to

take steps at admission and continues them through the patient’s hospital stay to assure a

successful transition. In addition to daily rounding’s/meetings, these steps include actively

teaching patient and family/friend caregivers to learn and practice self-care.

2. Clinician involvement and shared accountability during all points of transition. Both
sending and receiving clinicians are involved in and accountable for a successful

transition. They are identified by name and exchange information electronically or by fax

or telephone during the time of transition. At every point during the transition, the

responsible coordinating clinician is identified for the patient.

3. Comprehensive planning and risk assessment throughout hospital stay. Each patient
and family/friend caregiver has a discharge risk assessment completed during the hospital
stay, usually within the first 24-48 hours of admission. Discharge planning begins
immediately after admission. During the hospital stay, patients are assessed for risk

factors that may limit their ability to perform necessary aspects of self-care. Such risk
factors include low literacy, recent hospital admissions, multiple chronic conditions or

medications, and poor self-health ratings.

4. Standardized transition plans, procedures and forms. The following components are
included in a written transition plan or discharge summary: active issues, diagnosis,
medications, required services, warning signs of a worsening condition, and whom to
contact 24/7 in case of emergency. Plans are provided in the patient’s preferred language
and use pictures for patients having low literacy.

5. Standardized training. The organization begins by defining what constitutes a

successful transition. Staff are taught the necessary steps to complete a successful
transition and are engaged in real-time performance feedback. Successful transitions are
made an organizational priority and performance expectation.
6. Timely follow-up, support and coordination after the patient leaves a care setting.
Organizations develop a process that provides for timely post-discharge follow-up with
patients. Telephone or in-person follow-up, support, and coordination by a case manager,
social worker, nurse, or another health care provider 24-48 hours after discharge helps

patients achieve successful recoveries. A 24/7 call center provides a recently transitioned

patient or family member with information or reassurance after regular clinic hours.
Having a transitional care nurse accompany the patient to the first follow-up outpatient

visit can improve the health outcome, as can scheduling home care visits for the patient

7. If a patient is readmitted within 30 days, gain an understanding of the reason.

Readmissions within 30 days of discharge can often be prevented by providing a safe and
effective transition of care from the hospital to home or another setting. Convene a
meeting of the care team, including the attending physician and other key staff, and the
patient and family members.

8. Evaluation of transitions of care measures. Monitor compliance with standardized

forms, tools, and methods for transitions of care. Use surveys and data collection to find
root causes of ineffective transitions and to identify patient and caregiver satisfaction with
transitions and their understanding of the care plan.

CONCLUSION

Admission to ICU is often a short-term and critical period, but very significant experience
in ICU patients and has short-term and long-term effects on patients' recovery process. These
patients experience several transitions in a health care system. After the transition from the
ICU, the incidence of disorders such as post-traumatic stress disorder (PTSD), anxiety and
depression has been reported in these patients. Nurses can make significant contributions to
facilitating the process and can affect the long-term and short-term outcomes of the treatment.
The care needs to be adapted to the needs of the patient and his/her family. Therefore, proper
planning and care interventions are necessary in response to the transition of patients. In
conclusion, coaching of patients through transition is a central concept of nursing. Nurses are
challenged to consider all significant transitions in patients, and not merely health/illness
transition, which is most dominant. This challenge is even bigger for intensive care nurses,
because transitions are an understudied area in critical care nursing.
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