TRANSITIONAL CARE

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

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 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.

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 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

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 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.

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 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.

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 TRANSITIONAL CARE MODEL

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 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.

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 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.

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• 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.

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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

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 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.

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• 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.

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 CONCLUSIONS

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