Patients and family caregivers are vulnerable at points of exchange during care transitions between different settings (hospital, other institutional settings, and home). This often raises the risk of unfavorable health outcomes. The introduction of transitional care teams has made it possible for patients to move smoothly from acute care settings to their homes.
Compared to their traditional counterparts, nurses' roles "emerged differently." For the purpose of facilitating care integration, various nursing roles have been taken on. The coordination of care and prompt communication with important parties, such as families and community providers, that nurses provide during the discharge process help to ensure smooth care transitions.
Planning for Transition
Nurses acquire the knowledge necessary for successful transition planning through their interactions with patients and families. Creating and assessing the transition plan and identifying and communicating plan barriers, play a crucial role in fostering successful transitions.
Examples of these barriers include a lack of resources to cover PAC out-of-pocket costs and family members who are unable to provide care after discharge. To ensure that the transition plan is tailored to the needs of the patient and family and that patients are transferred to the appropriate setting, it is crucial to share this information with the interprofessional team early in the patient's hospital stay.
During care transitions, which are known to be a time when patients are particularly vulnerable, effective discharge planning can help reduce medical errors. Planning for discharge should involve both the patient and their caregiver and start as soon as the patient is admitted to the hospital. The IDEAL discharge planning strategy is one method that emphasizes patient and family involvement in discharge planning and discharge education.
Communication about medications
While it is crucial to include all relevant test results in the handoff communication, medication also requires special attention because it is the single biggest contributor to admissions. According to estimates, 30% of hospitalized patients' discharge medication reconciliations contain at least one discrepancy.
The area where there is the greatest chance for error and the greatest potential for success is in the communication of medication information. In actuality, adverse drug events account for over 66% of emergency readmissions for patients over the age of 65. Breaches in the handoff process, such as forgetting to include specifics about the patient's medication history and anticipated dosage requirements, have serious repercussions.
There are numerous reasons why a handoff goes wrong, but since nurses are key players in the transition communication process, you must strategically develop and communicate the transitional care plan. To do this, you must engage the receiving team in conversation and find out what information they believe is necessary to provide the best follow-up care.
Using Home Assistance Services
Depending on the patient's age and health, different types of support may be available. After older patients leave the hospital, some programs offer short-term care through specialized support services, while others offer basic support and maintenance services. This enables senior citizens to continue their healing outside of the hospital while suitable long-term care is organized.
Nurses and the rest of the medical staff will set up any required support programs for the patient when they are about to leave the hospital. Additionally, if patients and their families want to arrange for additional support once they return home, they will give them information about care services.
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