Transitional care

Transitional care refers to the coordination and continuity of health care during a movement from one healthcare setting to either another or to home, called care transition, between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. For young people the focus is on moving successfully from child to adult health services. Transitional care refers to the coordination and continuity of health care during a movement from one healthcare setting to either another or to home, called care transition, between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. For young people the focus is on moving successfully from child to adult health services. A recent position statement from the American Geriatrics Society defines transitional care as follows: For the purpose of this position statement, transitional care 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 homes, the patient’s home, primary and specialty care offices, and long-term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs. During transitions, patients with complex medical needs, primarily older patients, are at risk for poorer outcomes due to medication errors and other errors of communication among the involved healthcare providers and between providers and patients/family caregivers. Most research in the area of transitional care has studied the transition from hospitalization to the next provider setting – often a sub-acute nursing facility, a rehabilitation facility, or home either with or without professional homecare services. Adverse patient outcomes include continuation or recurrence of symptoms, temporary or permanent disability and death. Healthcare utilization outcomes for patients experiencing poor transitional care include returning to the emergency room or being readmitted to the hospital. As healthcare expenditures rise at an unsustainable rate there is increasing focus by patients, providers and policymakers on restraining unnecessary resource utilization such as that incurred by preventable re-hospitalizations. Transitional care or transition care also refers to the transition of young people with chronic conditions to adult based services. Transition care is a Youth Health service. As children mature into young adults, they outgrow the expertise of children’s services (paediatrics) and need to find an adult health service that suits them. A program in Australia GMCT Transition Care is an initiative aimed at improving continuity of care for young people with chronic health as they move from children's (paediatric) to adult health services. Continuity of health care (also called continuum of care) is to what degree the care is coherent and linked, in turn depending on the quality of information flow, interpersonal skills, and coordination of care. Continuity of health care means different things to different types of caregivers, and can be of several types: To avoid misinterpretation, the type of continuity should be agreed to before any related discussions or planning begin. Seamless care refers to an optimal situation where there is continuity in the healthcare even in the presence of many transitions. Analysis of medical errors usually reveals the presence of many gaps in health continuity, yet only rarely do gaps produce accidents. Patient safety is increased by understanding and reinforcing health care providers' normal ability to bridge gaps. The only currently nationally endorsed measure of transitional care quality is the Care Transitions Measure (CTM), which is a 15-item survey for administration to patients after discharge from the hospital. The measure also exists as a 3-item survey. Patient responses to the survey predicts return to the emergency department and/or hospital. Dr. Eric Coleman and his team at the University of Colorado at Denver and Health Sciences Center developed the CTM, as well as an intervention designed to improve patient outcomes during transitions.