Wise Health Care Consumer: Take an Active Role During Transition of Care
Everything You Need to Know About Transition of Care
By Tara Dontje, senior quality care coordinator at Network Health
7/29/2021
Navigating healthcare can be stressful and complex, and in many cases, can result in an ineffective “transition of care” leading to hospital readmission. At a cost of over $26 billion per year, these readmissions impact health care resources, financial reserves and patients’ long-term health outcomes.
You can help improve these outcomes by proactively participating in your transition of care.
What is transition of care?
Transition of care refers to the movement of patients between healthcare practitioners and settings of care during treatment for a chronic or acute illness as their healthcare needs change. Examples might include a patient who sees his/her personal doctor but also is evaluated by a specialist for a condition or illness, or a patient who needs to be hospitalized and is transferred from the hospital to a skilled nursing facility or back home.
This is often a vulnerable time for patients and requires a solid support system. Those most vulnerable during a transition of care are patients with complex chronic conditions and those lacking an adequate support network who can lend assistance and encouragement.
There are potential barriers to an effective transition of care
- Poor communication between providers and facilities
- Incomplete transfer information
- Lack of education and/or understanding of care by the patient or caregiver
- Limited or poor essential service during recovery
- Absence of a single point person to ensure continuity of care
How to prevent an unplanned transition of care
An unplanned transition of care is not always preventable, but following these steps should reduce the chance of such a transition.
Have a medical professional assist with coordinating your transition of care.
Many hospitals and health plans have designated care managers that specialize in community resources and health care transitions. The care manager functions as a central point of contact and coordination of care to promote continuity and effectiveness of your care to meet your individualized needs.
Network Health has skilled and knowledgeable care management teams. Our care managers can assist you and your family in successfully navigating a transition of care.
Use a support system
Have a family member, friend or partner/spouse attend any discussions regarding your care and discharge planning.
They may be able to assist you in addressing some of your needs or as questions you don’t think of. If you do have questions, write them down ahead of time so you don’t forget to ask them.
Ask for discharge instructions to be provided in writing
Many patients find the amount of information provided at discharge overwhelming. Having a written copy of the information allows you to review the information at your convenience and ensure you understand it.
Set follow-up appointments through your care manager
Making follow-up appointments can be easy to forget. Having your care manager do this will help ensure you receive the follow-up care you need
If your care is being provided by a doctor other than your personal doctor, request a copy of your medical records (including the hospital records) to be forwarded to your personal doctor for review. This will allow your personal doctor to assess if your condition has been resolved or requires further assessment and/or treatment.
Make care the constant in all health care transitions
An effective transition of care empowers patients to make informed healthcare decisions to maintain their health, independence and quality of life. For more information on how Network Health can assist with transition of care, contact us today.
