Transitions of Care
last authored: Jan 2010, David LaPierre
last reviewed:
get this: CHAMP - care of the hospitalized medical patient
Introduction
Successful transitions are efficient, include thorough transfer of information
smooth transition
prevent readmission
ensure appropriate follow-up orders
avoid medication errors
avoid duplication of treatments or investigations
avoid medico-legal problems
Over 35% of patients admitted to hospital are worse-off re: baseline ADLs on discharge (Covinsky, 2003). This means their discharge will require changes to their previous life.
There are many different times during transition
- admission to hospital
- in-patient transfers
- clinician to clinician, or team to team
- pediatrics to adults
- discharge home, to rehabilitation, or to assisted living
- on-call/holiday/weekend
The Case of Mr RM
Mr RM is being discharged after a three week admission for pneumonia. Her family arrives to pick her up, and are furious with me
Preparations for Transition
Simulate transition environment while in hosptial.
Documentation
Have good handwriting. Be thorough.
To improve effective transition for older adults (Dedhia et al, 2009)
CGA at admission
notification of primary care physician: fax/email a single page with details, asking for comments as appropriate
multidisciplinary team coordination:
medication reconciliation: physician-pharmacist collaboration; ensure you ask the patient
discharge meeting: ensure agreement among staff and patient/caregiver, with easy-to-read written information
Active advanced planning
- anticipation from first hopsital day
- admission social history: with whom does the patient live?
- what are the ADL and IADL capabilities?
- hospital course: delirium, deconditioning?
be aware and concerned about caregiver burnout
Needs to Consider:
housekeeping support
social support: emotional and IADLs
personal care
nursing care
- medications
- wound care
- catheters
medical care
Getting ready to go home checklist
- transition
- medication list
- medical supplies
- treatments
- moving around the home
- groceries and meal planning
- financial concerns
- follow-up appointments
Some places have a PCW that spend a few hours shopping
Communicating to Receiving Physician
Within one week, only 15% received the document within one week, and only 75% made it ever (Kripalani et al, 2007).
Choosing a Discharge Destination
Home with services
Recovering ADLs
sufficient and willing caregivers
- meds
- meals
- personal care
- etc
Nursing Home
Newly impaired ADL
unable to tolerate rehab
Requirements
accessible
affordable
temp
maint
safety
social capital
Additional Resources
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