High-Quality Care Transitions Promote Continuity of Care and Safer Discharges Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM
n A bstract
The care transition process is an essential part of healthcare delivery affecting patients and families, healthcare providers, and healthcare systems. The care transition, when instituted at the right time and in the right setting, has the powerful effect of smoothing a patient’s journey across the care continuum in a safe and effective manner, as well as informing the development of best practice guidelines (Dusek, Pearce, & Harripaul, 2015). Interdisciplinary collaboration, communication, and care coordination are among the vital components that support the care transition process. As such, these components are indispensable in assisting nurses and other healthcare professionals in understanding their roles and responsibilities as they work toward promoting a safe and positive care transition outcome. Today, healthcare systems across the country are carefully evaluating many care transition initiatives in order to adopt and/or develop their own best practices. When implemented at the right time and in the right way, care transitions enhance care delivery, improve patient outcomes, and move organizations toward successful attainment of the triple aim: better health, better care, and lower cost through improvement. This article defines and describes the care transition process and its potential to influence continuity of care and patient safety. When actively incorporated into patient care delivery, both during and post hospitalization, this process builds collaborative patient-centered relationships, which in the long term may have the positive effect of troubleshooting post-discharge problems, thus mitigating potentially avoidable readmissions.
What Are Care Transitions? The concept of care transitions has been on the healthcare radar since the early 2000s. Dr. Eric Coleman (2004) defined care transitions as a set of actions designed to ensure care coordination and continuity as patients transfer between different locations or different levels of care within the same location. Over time, this definition remains essentially unchanged. Accordingly, Clark, Doyle, Duco, and Lattimer (2016, p. 3) in their Joint Commission publication, “Transitions of Care: The need for a more effective approach to continuing patient care,” similarly noted that a care transition refers to the movement of patients between healthcare practitioners, care settings, and home.
Although one episode of care might entail many transitions, much of the literature describing these transitions shows they are coordinated pathway(s) through and across healthcare systems. Such transitions can be manifold—from department to department, institution to institution, and/or from facility to home (Cobler, Wang, Stout, Piejak, & Rodts, 2017; Deravin Carr, 2008; Coleman, 2004). Among most commonly seen patient care transitions are those occurring during the hospital admission process— between the emergency department (ED) and inpatient units—and again at discharge to the community. Figure 1 provides an example of the multiple transitions of care that can occur within healthcare systems.
Dana Deravin Carr, DrPH, MS, MPH, RN-BC, CCM, Jacobi Medical Center, Bronx, New York 4
Journal of the New York State Nurses Association, Volume 46, Number 2
