Health care administrators and nursing staff have become increasingly aware of the need for high-quality transitional care, especially among at-risk patients like seniors. As a current or aspiring health care administrator, you have the capacity to make a real difference in the lives of vulnerable patients in your community. Stay abreast of the latest research on transitional care, coordinate with other decision makers at your organization and continually look for ways of improving and expanding services to better meet the needs of your patients.
Identifying the Challenges of Transitional Care
Transitional care is usually thought of as transferring the care of the patient from one facility to another, such as a hospital to a post-acute care setting. Administrators should think more broadly about transitional care, and recognize that there are inherent challenges involved with transitioning to home care, as well. When any transfer of care occurs, there are, unfortunately, too many opportunities for critical information to get lost in translation. For example, a patient with dysphagia and a peg tube might be transferred to a nursing home with orders for a general diet. Inadequate transitional care can result from:
- Poor communication
- Inadequate patient and family education
- Inadequate discharge planning
- Limited access to needed resources and services
As a result of the many challenges associated with transitional care, these patients can be at a higher risk of:
- Hospital readmissions
- Medication errors
Completing Proactive, Collaborative Discharge Planning
One possible way to improve care transitions in your own health care facility is to begin discharge planning sooner. At an acute care hospital, discharge planning could begin as soon as the patient is stabilized, or even earlier if the patient is having a planned procedure. Post-acute care facilities like long-term care and nursing homes can begin discharge planning as soon as they receive a new patient. This process would involve identifying the length of the patient’s stay in order to allow him or her to achieve the functional goals necessary to return home. By conducting discharge planning in a proactive way, in collaboration with the family, the family members have more time to arrange the patient’s needed services.
Conducting Functional Assessments
All patients should have a comprehensive functional assessment as part of the care planning process. Before a patient leaves a hospital to be transferred to a post-acute setting, the clinicians and staff must fully understand the patient’s cognition, mobility, activities of daily living and all other functional statuses. A full functional assessment may help in making a more appropriate choice of care facility.
Performing “Warm” Handoffs
Despite all the technology available to health care providers today, nothing can quite replace face-to-face contact. Health care administrators may consider requiring more warm handoffs, in which the care coordinator at the hospital meets face to face with the staff member from the long-term care facility. This affords them the opportunity to discuss health history and care orders, and it can reduce complications like medication errors.
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