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.

1. TRANSITIONAL CARE
DR.VINOLI.S.G
Professor
HOD Medical Surgical Nursing Dept
Universal College Of Nursing
Bangalore

2. INTRODUCTION
Transitional care is a broad term that
encompasses a variety of intermediate care
services, including sub acute, skilled, and
rehabilitative care services.
Transitional care bridges the gap
between hospital and home for patients
with complex or multiple problems.
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3. MEANING
Meaning of "Care Transitions"
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.
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4. DEFINITION
Transitional care or care transition is defined
as a set of actions designed to ensure the
coordination and continuity of health care as
patients transfer between different locations or
different levels of care within the same location.
Representative locations include (but are not
limited to) hospitals, sub-acute and post-acute
nursing facilities, the patient's home, primary and
specialty care offices, and long-term care facilities
-American Geriatrics Society
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5. Need of Transitional care in ICU
Critically ill patients in the intensive care
unit often experience a lot of changes as
they move through different levels of care.
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6. ELEMENTS OF TRANSITIONS OF CARE
• Communication
• Changes in plan of care
• Medication reconciliation
• Follow-up tests and services
• Education of the patient and family
• Transfer of all information when site of care changes
• Involvement of team during hospitalization,
discharge, follow-up, etc.
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7. TRANSITIONAL CARE MODEL
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8. Uses of care transitions intervention
• Patients who received this program were:
– Significantly less likely to be readmitted.
– More likely to achieve self-identified personal
goals around symptom management and
functional recovery.
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9. BARRIERS TO SUCCESSFUL TRANSITIONS
Barriers to effective care transitions at three levels:
• The Delivery System
– The lack of formal relationships between care settings
represents
– Lack of financial incentives promoting transitional care
– The lack of information systems designed to facilitate
the timely transfer of essential information.
• The Clinician
– Nursing staff shortages
– Clinicians do not verbally communicate patient
information to one another across care settings.
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10. • The Patient Barriers
– Lack of advocacy or outcry from patients for improving
transitional care until they or a family member is
confronted with the problem firsthand.
– Older patients and their caregivers often are not well
prepared or equipped to optimize the care they will
receive in the next setting.
– They may have unrealistic expectations about the content
or duration of the next phase of care and may not feel
empowered to express their preferences or provide input
for their care plan.
– Patients may not feel comfortable expressing their concern
that the primary factor that led to their disease
exacerbation was not adequately addressed.
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11. KEY COMPONENTS OF SUCCESSFUL TRANSITIONS
• Focus on Patient and Caregiver Understanding
• Helping Patients Manage Health Issues and
Prevent Decline
• Medication Reconciliation and Management
• Transitional Care, Not Ongoing Case
Management
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12. Role of Transitional Care Nurse
• The TCN role is very different from a traditional
nursing position. It incorporates the skills of a
nurse, care manager, and patient advocate and
knowledge of evidence-based care, managing
complexity, palliative care, active engagement of
family caregivers, interdisciplinary team care,
theories and strategies for individualized care and
behavioral change, quality improvement, and
organization, delivery and financing of services
across an episode of acute care.
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13. • Healthcare transitions ensure safe and
efficient movements of patients between
different sectors of care within the healthcare
system.
• Transition as a concept is central to the
nursing discipline as a whole. Nurses often are
the primary health professionals involved in
encounters with patients and their families
that relate to transitional periods of instability.
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14. CONCLUSIONS
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