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Transitions of Care: Promoting Safe and Quality Patient Care

February 27, 2017

For patients, the healthcare spectrum is a string of transitions, whether it is a physical transfer between healthcare facilities or a change of physician. Communication around patient care is critical in that we must communicate exact information at each change of care to provide the next caregiver with the necessary information to start care without having to read the chart from the beginning or until the healthcare provider can assess the patient themselves.

Examples of transitions include:
* Handovers at shift changes
* Patient transfers to various units within the facility setting
* Patient discharges to another healthcare facility or to home
* Patient referrals to other health services providers such as home care programs(e.g., visiting nurses) or other healthcare practitioners in the community (e.g., physio, occupational therapy)

Care coordination is a “shared responsibility” among all healthcare providers involved in a patient’s care. However, in reality, there are gaps in communication about the patients’ care-between hospital and healthcare providers, among healthcare providers, and between long-term care settings and hospitals or other healthcare providers. While a best practice is for hospitals to send a patient’s discharge information to all the patient’s providers, staff can be overwhelmed trying to identify those healthcare providers.

From primary care to specialized cancer care, from hospital to long-term care, from patients’ electronic medical records to clients receiving information about a new medication, providing patient care is not one person’s responsibility. It involves all healthcare care providers working in true partnership with patients and their families, and the effective transfer of complex information.

On the flip side, poorly coordinated care has a significant impact on patients and their families. For example, if your family member is in a long-term care home or hospital, would you expect specific steps to be taken to coordinate services and effectively transfer information? Would you expect processes and strategies to be in place at each location where care is provided to safely administer medications and to prevent falls?

Electronic health records (EHRs) can facilitate communication about a patient’s care among healthcare providers, but organizations must establish procedures that address accessing, reviewing, and acting on the findings in those records. For example, what happens if a healthcare provider who is viewing a patient’s record discovers that results of tests ordered by another provider have not been acted upon? It is hoped that healthcare organizations identify a policy specifying procedures for a healthcare provider who finds an abnormal laboratory or pathology result with no indication that the abnormal result was acted upon.

With increasing pressure to shorten hospital stays, many patients are discharged to post-acute care settings to continue their rehabilitation, such as post stroke care or rehabilitation following joint replacement surgery. But communication breakdowns can occur between hospitals and that next level of care. It has been reported that there are opportunities for missed information transfer, errors in information, and errors in orders when patients are transferred to the post-acute care setting.

Considering how many transitions occur daily, care transitions are critical and vulnerable points in the healthcare care system during which the communication/transfer of information may be less than optimal. Breakdowns at care transitions create safety risks for patients and increase costs to the health care system. There is a common understanding that care transitions are key to high-quality health care across the continuum. Yet, care transitions continue to be recognized as a critical opportunity for system improvement given health care provider workload.

Tied to transitions of care, are those that relate to medication management. It is important that healthcare providers have access to medication profiles of patients; and that healthcare providers know they need to ensure that patients know who to contact if they have questions about their medications. Additionally, knowing the patient’s understanding of their medications and specific issues are discussed.
For example:
* Ensure there is an effective information transfer at transition points such as admission or discharge from hospital
* Develop and implement a plan for medication reconciliation
* Conduct medication reconciliation at admission
* Conduct medication reconciliation at transfer or discharge

As healthcare providers build more arrangements to ensure care coordination, it’s important to remember the patient during the various transition phases. The patient is quite often overwhelmed by their disease process and by navigating the system. Whether a discharge planner in a hospital, or other care coordinator, someone needs to help the patient, especially an elderly patient, to remind them to make appointments, to take medications, and to help them know what to ask and expect at their next healthcare visit. Ensuring patients understand their conditions and self-care responsibilities is another critical component, as it may improve their adherence and their engagement in their care and care coordination.

Reference: Accreditation Canada

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