Creating A Smooth Transition Of Care

Home Health Nurse in NY

Change is usually a difficult thing to go through because of the various unknown possibilities that await you on the other side. Those who are despairing can perceive change as a good thing with the possibilities of an intermission from pains or discomfort. However, those unknown expectations still exist. Individuals who go through transitional care may go experience this sentiment and be fearful of new environments. Transitional care is the combination of services that provide a safe and timely shift between different levels of care. This is extremely important for individuals with chronic diseases or illness considering that they are more susceptible to injury or further complications. It is never easy transitioning your elderly parents or loved one to a new setting, which is why it is paramount to ensure they have a smooth transition of care. Here are a few ways to help make a smooth transition from or to the hospital, nursing home, assisted living facility or even back home.

Communicate Effectively:

Miscommunication amongst healthcare providers can lead to a poor transition of care. According to the Agency for Healthcare Research and Quality, “Transitions increase the risk of adverse events due to the potential for miscommunication as responsibility is given to new parties.” Caregivers play such a critical role in ensuring a smooth transition of care because they take on the responsibility of providing the patients current medications, allergies or other health issues as well as planning their next site of care. According to NCBI, “hospital readmissions may result from failures in communication as well as from poor coordination of services, incomplete treatment, incomplete discharge planning, and/or inadequate access to care.” With this in mind, it is important for assisted living facilities to have a well developed relationship with skilled nursing facilities to reduce readmissions from a poor transition of care.

Caregiver for HIV Patient

Prevent Incomplete Discharge:

Proper discharge from any setting is paramount in confirming a smooth transition of care. An incomplete discharge can be detrimental to patients health. As explained in an NCBI publication, “nearly 30% of older people experience some delay in their hospital discharge, which is known to expose patients to additional hospital-related risks, create emotional and physical dependency, incur additional hospital costs.“ The Continuity Assessment Records and Evaluation tool created by the CMS can assist throughout your transition of care. This tool not only provides up-to-date information of discharge but also includes, a standardized assessment of the patient’s medical, functional, cognitive, and social conditions throughout environments of care. Ask your healthcare professional if this tool is available at your hospital or nursing home.

Get Support:

The process of moving between different healthcare settings can be overwhelming and scary to some people. Nonetheless, there are transition coaches, programs and services that can aid you along your journey. These transition coaches are advanced nurses that educate both the patient and caregiver on specific skills needed to promote a smooth transition of care. Studies have shown that, “hospital costs were approximately $500 less” and “had lower all-cause re-hospitalization rates through 90 days after discharge,” for patients with transition coaches. Ask your healthcare professional if this service is available at your hospital or nursing home.  Transitional care programs are also available through some home care agencies and have been known to reduce re-hospitalization by less than 3%. Many assisted living and memory care communities have special associates designated to focus on the transition with special programs to welcome new residents.

At Renaissance Home Health Care, we follow all necessary safety precautions to ensure that there is a smooth transition of care to and from our facilities. It is imperative to keep a positive attitude and communicate with clients, members, and each other. We understand that this process is important and can affect both the client and caregiver. Our goal is to ease the recovery process and prevent hospital readmission by ensuring a smooth transition of care to and from our facilities.