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Care Transitions FAQs

Q: What does the term “care transitions” mean?

A: “The term care transitions refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. For example, a patient might receive care from a General Practitioner (GP) or 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 skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse.  Each of these shifts from care providers and settings is defined as a care transition.

Q: Why are hospitals interested in care transitions programs?

A: Impending cuts to Medicare spending will likely motivate hospitals to seek solutions within for reducing readmission rate since those rates will start to impact the Medicare payments they receive.  

Q: Should all hospital readmissions be prevented?

A:  No, not all readmissions are preventable.  If the cause for the readmission is not tied to the original admission then a patient should not be prevented from returning to the hospital.  It may also be necessary to readmit a patient even if the cause is tied to the original cause for admission. The objective for reducing preventable readmission is to increase the patient’s well being while also reducing the hospital’s cost but one should not occur at the expense of the other.

Q: What are some of the problems associated with poor transitions between settings?

A:  The following are some of the outcomes associated with poor transition management:

  • Information is often fragmented in silos and there is poor communication between settings;
  • There is often misunderstanding or confusion on the part of the patients and their family caregivers about how and who should manage their care;
  • Medication errors may occur due to misunderstanding of instructions, medication adherence, drug-drug interactions and duplicate prescriptions;
  • Inadequate or poor follow up with General Practitioner (GP);
  • There is a general lack of knowledge about alternatives (i.e. home care providers) in many communities.

Q: How can Right at Home services help improve transitions of care to effectively reduce the number of preventable readmission rates?

A: Right at Home caregivers may be able to assist patients at home in the following ways:

  • Observe red flags, provide documentation and report back to the hospital (or Physician) on the patient’s progress to avoid an adverse event;
  • Transport patients to and from Doctor’s visits to assure appropriate follow up;
  • Assist clients with medication reminders to deter medication errors;
  • Offer meal preparation to adhere to a patient’s dietary restrictions;
  • Provide ambulatory assistance to lessen the likelihood of a fall.