Transitional care (TC) supports patients moving between different healthcare environments, such as transferring from a hospital to home or a rehabilitation facility. This proactive approach ensures the coordination and continuity of health services. TC begins before discharge and often continues for a set period, commonly up to 30 days, following the patient’s departure from an acute care setting. Its primary function is to create a seamless handover of responsibility between the acute care team and the patient’s next providers or caregivers.
Defining the Scope and Purpose
Transitional care addresses the high vulnerability patients face immediately following a hospital stay. During the shift from intensive acute care to a lower level of support, patients are at risk for preventable adverse events, including medication errors or complications from their illness. The purpose of TC is to mitigate this risk and reduce the rate of unplanned re-hospitalizations, particularly those occurring within 30 days of discharge.
TC aims to secure better long-term health outcomes by aligning the efforts of multiple providers and preventing fragmentation of care. The rise of these models is tied to new payment structures, such as those utilized by the Centers for Medicare & Medicaid Services (CMS). These alternative payment models incentivize healthcare providers to prioritize quality and coordination over the volume of services delivered. They reward providers for successfully reducing readmission rates and overall costs by improving care transitions.
Core Activities of Transitional Care
Comprehensive Medication Reconciliation
Comprehensive Medication Reconciliation compares the list of medications a patient was taking before admission with the new list prescribed at discharge. This process identifies and resolves discrepancies, such as duplicate drugs, omissions, or incorrect dosages, which frequently cause adverse drug events. Pharmacists often lead this task, reviewing all medications, including over-the-counter drugs and supplements. The goal is to create a single, accurate list that the patient understands.
Patient Education and Health Coaching
Patient Education and Health Coaching empowers the individual to manage their recovery and chronic conditions effectively. This involves teaching patients and their families about their diagnosis, warning signs of complications, and self-management techniques. The “teach-back” approach is a common method, where the patient repeats instructions to confirm understanding of their follow-up care plan. This coaching helps patients recognize symptoms that require immediate medical attention, preventing escalation into a re-hospitalization.
Logistics and Follow-Up Planning
Logistics and Follow-Up Planning ensures a smooth transition to the patient’s next care setting. This includes scheduling necessary follow-up appointments with physicians before the patient leaves the hospital. The team also coordinates the delivery and setup of any required medical equipment at the patient’s residence. Planning also involves confirming transportation arrangements and connecting the patient with community resources, such as food assistance or home care services.
Patient Triggers and Care Settings
The need for TC is “triggered” by clinical and social factors that indicate a high likelihood of re-hospitalization or adverse events. Primary candidates include patients with multiple complex chronic conditions, such as congestive heart failure (HF), chronic obstructive pulmonary disease (COPD), or diabetes. Other triggers include a recent history of multiple hospitalizations, a complicated medical regimen, or cognitive impairment that compromises the ability to follow instructions. Social factors, such as living alone or lacking reliable caregiver support, also increase the need for TC services.
Transitional care is delivered across various settings, depending on the patient’s medical needs and destination after their acute stay. The most common transition is from the hospital back to the patient’s private home, where support is provided via phone calls, home visits, or outpatient clinics. For patients requiring more intensive post-acute care, the transition may be to a skilled nursing facility (SNF) or a transitional care unit (TCU) within a hospital. These facilities provide short-term rehabilitation and skilled nursing services before the patient is stable enough to return home.
The Transitional Care Team
The Transitional Care Nurse (TCN)
The Transitional Care Nurse (TCN) often serves as the central coordinator and the patient’s primary point of contact. The TCN manages the overall plan of care across settings. This role involves hands-on patient education, conducting post-discharge follow-up, and ensuring seamless communication between the hospital, primary care physician, and the patient.
Social Workers
Social workers focus on the non-medical, biopsychosocial elements of the patient’s recovery. They assess socioeconomic barriers, such as housing instability or lack of transportation. They connect patients with appropriate community resources and support systems. This addresses how factors like poor living conditions and lack of access to basic resources influence a patient’s ability to maintain health after discharge.
Pharmacists
Pharmacists contribute specialized knowledge to ensure medication safety. They work to resolve drug-related problems and assess a patient’s financial ability to afford their prescriptions. Pharmacists also counsel patients on proper administration and potential side effects. This collaborative effort ensures that both the medical and logistical needs of the patient are addressed, strengthening the continuity of care.