Transitional Care

Among hospitalized patients 65 or older, 21% are discharged to long-term care or another facility and can expect to see an average of 10 different physicians during the course of one health event. If not handled smoothly, these care transitions can potentially be dangerous as changes in care settings, providers, and medications can result in errors that lead to complications and readmissions.

The term care transitions refers to the movements patients make from one health setting to another. Most people think of transitioning from hospital to home, but transitions can be in any direction – long-term care to acute care and back, acute care to rehab, rehab to home, and even within departments of the hospital, such as ICU to acute care. Transitional care encompasses both the sending and the receiving aspects of the transfer, and successful transitions are essential for older adult patients with complex care needs.

Patients may be moved 3-6 times during their hospital stay, which can cause missed or delayed treatments, medication errors, and patient falls, and result in contact with as many as 100 healthcare providers during hospitalization. Typical nursing units may transfer or discharge 40-70 % of their patients every day.

For example, a patient might receive care from a specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission, before moving on to yet another care team at a rehab facility. Finally, the patient might go to long-term care or return home, where he or she would receive care from a visiting nurse.

Approximately 25% of Medicare skilled nursing facility residents are readmitted to the hospital. With decreasing reimbursements and penalties for readmissions, healthcare systems worry they will have to absorb unsustainable costs.

The Nurse’s Role
Nurses are an important part of making care transitions seamless. Best practices in transitional care rely on 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 all health professionals involved in the transition.

NICHE, a nurse-driven program based at New York University’s College of Nursing, provides a number of resources and educational tools that help nurses ensure successful transitions and optimum continuing care for older adults.

“As nurses, we know that many times things can be going smoothly until it is time to transition. It seems that this is when snags and bumps can occur,” said Tonya Maunsell MSN, RN-BC, OCN, charge nurse and NICHE Program coordinator, Christus Santa Rosa Hospital Medical Center, San Antonio.

Maunsell educates the nursing and support staff on elder care principles and protocols, and together, she and her colleague Imelda Sanchez, MSN, RN, director of geriatric services, monitor the care provided to geriatric patients. Through education and training, staff has been taught to look for issues that could hinder or prevent the transition of a patient.

Of course, nurses are the ones who are in the trenches with patients and families. They often know more about what is going on with each patient than any other team member. One of the most important issues nurses should be aware of is the patient’s level of functional ability. “If we let a patient stay in bed all day, functional ability is going to decline. However, we also need to be aware of what their functional ability was prior to admission and not expect a total reversal overnight. In addition, nutrition, sleep, and pain control are all factors that can potentially improve or impair the patient’s abilities,” Maunsell said.

The role of nurses in transitional care is vital, agreed Carla Graf, PhD, RN, GCNS, interim director of clinical programs for the Office of Population Health and Accountable Care, University of California, San Francisco Medical Center, also a NICHE hospital. By training, nurses are holistic, considering the psychological, physiological, and social issues impacting illness and recovery, she said.

Bedside nurses assess patients, design and implement care plans, and educate them about medications, self-care, activity, diet restrictions, and important symptoms or red flags to look for – all in preparation for discharge.

Nurse case managers assist the team with discharge planning needs such as use of home care, durable medical equipment, and any additional care coordination needed, such as physical therapy.

Nurses in home care help patients carry out discharge instructions. They teach and reinforce self-care management skills, and communicate with the rest of the care team about patient status.

In any setting, nurses are the coordinators of care among various disciplines. “Nurses need to be aware of the importance of their role in transitions, no matter what their practice site. They also need to be aware of how overwhelming even a simple hospitalization can be for any patient, no matter their level of support or education. They need to understand the issues that arise for patients after discharge and work as part of a team to mitigate risk,” Graf explained.

Nurses at NICHE hospitals across the country are instrumental in developing successful and innovative transitional care programs.

Case Study: Restorative Aides

At the 2015 Annual NICHE Conference in Orlando, Maunsell and Sanchez presented a poster on their transitions research, titled “Effectiveness of a Restorative Aide: Moving the Patient Across the Continuum of Care.”

To limit functional decline during an older adult’s hospital stay, Christus Santa Rosa Hospital Medical Center undertook a plan to keep patients active. The interdisciplinary team took the following steps:

  • Assess the patient’s functional status on admission and daily.
  • Ensure early mobilization.
  • Tailor activity to meet the patient’s needs.
  • Walk patients in the halls daily, where applicable.
  • Get patients up to the chair for all meals.
  • Promote socialization by encouraging patients to dine together as a group (unless contraindicated).
  • Bedbound patients receive detailed range-of-motion exercises (both active and passive).

To carry out this initiative, Christus Santa Rosa used restorative aides. As the duties of the registered nurse become more complex, restorative aides are tasked with spending more time with patients and engaging them in social and physical activities. Not only does this help decrease the length of stay, they explained, but it helps patients maintain mobility, independence, and the ability to be discharged home.

As restorative aides work to keep patients active, they are helping to preserve and even improve their functional ability. Through the restorative aides’ work, the demand on nurses decreases. Many times, a restorative aide can identify a particular patient need that had gone unnoticed. Additionally, through the socialization in group activities provided by restorative aides, patients and families have a higher level of satisfaction with the hospital experience, they reported.

Case Study: Phone Call Program
In another 2015 Annual NICHE Conference poster session, Graf and Margaret Emrick, BSN, RN, administrative coordinator at UCSF Medical Center, showcased “A Positive Discharge Touch: Implementation of a Centralized Nurse-Led Hospital Discharge Telephone Call Program.”

Telephone follow-up after hospital discharge is a best practice to support patients during the transition period to clarify discharge instructions, review medications, evaluate symptoms, and facilitate outpatient handoffs.

UCSF Medical Center re-engineered and expanded its follow-up phone call program for inpatients, the ED, and perioperative services. Previously at UCSF, manual calls were initiated by unit RNs working a few hours per week calling their patient populations. The calls were clinical only and had no satisfaction questions. Implementation goals of the new program were to attain and sustain a reach rate of at least 75%, understand patient needs in the acute transition period, and capture timely clinical and satisfaction data and feedback.

Here’s how it worked: An automated call was sent to patients within 48-72 hours after discharge. Patient needs were identified and queued for trained RNs. An RN called back to resolve clinical and satisfaction issues. Nurses documented call outcomes and notified providers, and all data was captured and reported.

Patients received a call back based on their responses to these questions:

1. Are you having any new or worsening symptoms since leaving the hospital?

2. If you were given a prescription, were you able to fill your prescription?

3. Have you started taking your medications?

4. Do you have any questions about your medication?

5. Do you need help making a follow-up appointment with your doctor, home care, or physical therapy?

6. Were you satisfied with your stay at UCSF Medical Center?

Telephone follow-up within 48 hours of hospital discharge can ensure the patient is implementing discharge instructions, is planning to attend a follow-up appointment, and that home care has called or arrived. These issues are especially important for complex, high-risk, and older adult patients.

“What has been surprising for us is that despite having made many improvements in our discharge process, many patients still want to talk to a nurse after discharge,” said Graf. The issues are variable, but tend to cluster around care coordination, medications, and symptoms, she said. “Often they are doing all the things they should be doing, but want reassurance now that they are home.

“We never know which patients will go home and have a significant side effect to a medication, who may have new symptoms and need to move up their follow-up appointment, or who might go to urgent care or the ED. No matter how much we improve the discharge process, it is difficult to apply a one-size-fits-all approach to transitions,” she noted.

Avoiding Transition Mistakes
To avoid mistakes in the transitions process, be proactive. Many times when older adult patients are admitted to a facility, they are encouraged to stay in bed and rest. Patient needs may go unnoticed. If staff doesn’t encourage mobility, a patient could be discharged without the ability to ambulate unassisted. The patient will then require at-home physical therapy, an assistive device, or even a stay at inpatient rehab, when all of this could possibly have been avoided.

Maunsell and Sanchez believe the role of the restorative aide should be part of the standard of care for all patients, leaving them less likely to fall through the cracks.

Another potential problem is assuming patients understand everything we teach them, Graf said. “We go to great efforts to start discharge planning early, and to make discharge instructions as easy to understand as possible. However, despite patients/caregivers being able to do return demonstrations with us while in the hospital, once they get home it can be a very different experience for them.”

Equipment may not look the same as it did in the hospital. There is no one there to answer questions. Medications can be especially confusing. “We also cannot underestimate the effect of being acutely ill, stressed, sleep deprived, and in pain on a patient’s ability to remember instructions or to be able to execute at home what seemed straightforward while they were surrounded by providers and caregivers in the hospital setting,” Graf pointed out.

When transitions do not go smoothly, consequences to the patient include adverse drug events or readmissions to inpatient, emergency, or urgent care. Patients and their caregivers may feel abandoned, frustrated, and ultimately not satisfied. Having a point of contact at each location is a must during the transition period to expedite communication if problems do occur.

The National Transitions of Care Coalition also outlines the following recommendations to achieve successful care transitions:

  • Improve communication during transitions between providers, patients, and family.
  • Implement electronic health records that include standardized medication reconciliation.
  • Expand the role of pharmacists in respect to medication reconciliation.
  • Establish points of accountability for sending and receiving care.
  • Increase the use of case management and professional care coordination.
  • Implement payment systems that align incentives.
  • Develop performance measures to encourage better transitions of care.

NICHE provides a number of resources to help nurses, patients, and caregivers with transitions, including the NICHE for Patient+Family mobile app. Nurses/clinicians can recommend use of many of these to patients and their families. For more information, including educational tools, handouts, and webinars on transitions, visit the NICHE website at

Elizabeth Rosto Sitko is a freelance writer in Plymouth Meeting, Pa.

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