When a patient is in need of long-term care due to acute, chronic, or long-term illnesses, they may go through what’s referred to as “care transitions.” This is when a patient is transferred from one “set of hands” to a new “set of hands.” This can occur when a patient changes nursing home facilities or is moved from the hospital to a long term care facility. These transitions are important since the patient’s consistent care is being passed off to a new team. This is a big responsibility for both old and new caregivers. One, it’s the responsibility of the old team to pass on every detail of information needed for the best-continued care of the patient. Further, it’s the responsibility of the new team to ask questions, read charts, and learn the patient’s details, needs, history, etc. This ensures top-notch care of a patient. The following covers some of the basic foundations and the best practices for care transitions.

The Basic Foundations

The TJC is “The Joint Commission” which is a large medical accreditation organization. They state seven rules as the basis for a strong foundation in care transitions. These foundational steps and guidelines ensure patients receive the best care possible during their transfer.

TJC’s seven rules are as follows:

  • Early identification of patients at risk
  • Leadership support
  • Medication management
  • Multidisciplinary collaboration
  • Patient and family action/engagement
  • Transfer of information
  • Transitional planning

Best Practices

The TJC states that when followed, these rules provide what is considered the best practices when handling care transitions. A successful care transition will be where a team participated fully in the transition and used the most up-to-date guidelines throughout the process. To be more detailed, the transition should involve regular assessments of the patient, strong communication with the patient and everyone involved, a well-managed process, and a patient care model that was adhered to. Most importantly, the patient remained number one and at the forefront of every decision made and every step taken.

A patient care model can be different for each transition since each patient will be unique in their needs. Be sure there’s a plan in place that’s clear and organized so the entire team is on the same page. The more organized a care transition is, the smoother it will go, and the safer and better it will be for the patient.

Care transitions happen often and it might be easy to get into the routine of just getting them over with. However, it’s important to remember that each patient relies on the job that was done and there can be consequences concerning their life and health if it’s done poorly. Overall, the patient and the success of their health is the entirety of the position, making a care transition vitally important to the success of your job as a whole.