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How do you manage patient care transitions?

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Patient care transitions are the movements of patients between different settings, providers, or levels of care within the health care system. They are critical moments that can affect the quality, safety, and outcomes of patient care. However, they also pose many challenges and risks, such as communication gaps, medication errors, readmissions, and patient dissatisfaction. As a case manager, you play a vital role in facilitating and coordinating patient care transitions. Here are some tips on how to manage them effectively and efficiently.

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1 Assess the patient's needs and preferences

Before planning any care transition, you need to assess the patient's needs and preferences, as well as their current condition, goals, and resources. You should involve the patient and their family or caregivers in the assessment process, and respect their values and choices. You should also identify any potential barriers or risks that might affect the transition, such as social, financial, or environmental factors, and address them accordingly.

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Muhammad Eltawansi

Patieny Savior | Physician | Qualitician | Speaker | Master trainer | Learner | Researcher | MBA, CPHQ, CPPS
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A patient-centric approach to care transitions begins with a thorough assessment involving patients and their support network. It considers not only medical needs but also personal values, preferences, and social factors. Identifying and addressing potential barriers ensures a safer and smoother transition, ultimately improving the overall quality of care.

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Nova Woods BSN, RN, CMCN

Team Lead Clinical Appeals | Registered Nurse-Compact Licensure
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It’s important to take the time to have an honest conversation with the patient you are assisting. Clearly, in some situations this isn’t possible, but taking the time to talk to the patient directly, in a way they can understand, to find out THEIR goals and needs, but also support, etc. is crucial. If something is cost-restrictive or something the person needs to work for (ie IRF vs SNF) be honest with the patient about what is required and involve the care team. Be prepared to compassionately listen to the frustrations (there will be some) and offer useful and honest information. Be prepared to offer alternatives and explain the “why.” ie If you know that X facility is hard to get into, suggest the person have other facilities in mind.

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Kimberly Allen

Lived Experience Stakeholder Advisor
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Utilizing peer support services is very helpful and efficient, particularly in times of transition. For example, mental health peer supporters who know the community and who match the patient in terms of culture, diagnosis, background and the like.

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Dr. Nicole L. Arkadie, Ed.D, LCSW, PPSC

Mental Wellness Strategist | Public Speaker| Assistant Professor | Scholar Practitioner | Published Author | You Matter Too, So Take Care of You!
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When transitioning a patient/client to another provider, a different level of care, or termination of current services, collaboration is a must. Therefore, having a collaborate mindset is key. The practitioner or medical professional must utilize a collaborative approach with their patient/client and not be dismissive of what the patient deems as important information to take into account. The medical practitioner must listen to the patients needs, while also discussing and supplying their own professional expertise of what is needed thus aiding in providing a safe and effective transition.

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Catherine Bartholome

Retired RN
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It's helpful to communicate the transition plan both verbally and in writing, and to seek feedback from each party to assess correct understanding. When available, family members of a patient can be advocates to facilitate a smooth transition.

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2 Communicate and collaborate with the care team

Communication and collaboration are essential for successful care transitions. You need to communicate and collaborate with the care team members involved in the patient's care, both within and across settings. You should establish clear roles and responsibilities, share relevant information, and use standardized tools and protocols. You should also communicate and collaborate with the patient and their family or caregivers, and provide them with clear instructions, education, and support.

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Jill Huntington-Bayless

Licensed Professional Mental Health Therapist @ Rock City Counseling
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I am completely transparent about what I can and cannot bring to the table. I am also just a human traversing this existence. I do not portend that academia nor "expertise" enlightens me beyond something another brings to bearing. I bring only, presence, care, a fully listening personhood and empathy that at times is so palpable I stop breathing when a person is holding their own breath. Who are we? But vessels to spur and love and attempt to relate to our fellow humans.

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Nicodemus C.

What world will we create, when we let ideas from (seemingly polar and) diverse professional worlds interact? \ Registered Social Worker, Counsellor, Training, Strategic Partnerships, Business Development, Consulting
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As care professionals, we have to be cognisant of our service’s role and also limits, whilst also being cognisant of other care partners’ roles and limits. An important first task is to conduct a case conference with all the care professionals involved from various agencies to synchronise knowledge of patient. Right after, a group chat with the partners be formed for quick, collective response. Moving on, each partner needs to add to the collective trust and deliver what they promised to client & to other professionals. On a macro level, if you are a social worker, embrace your ecosystem-builder duty. Initiate time for agencies serving in the locale. Each country, town, county, village will differ, so use your hyperlocal expertise.

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Megan A. Monfordini

Physician Recruitment at Medical University of South Carolina
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Collaboration with your patient's clinical and familial team is vital to their success moving forward. Modeling what that communication should look like for them, on a regular basis, is nothing short of a little bonus to ensure they are able to continue to advocate for themselves.

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3 Coordinate the care plan and services

Coordination is another key aspect of managing care transitions. You need to coordinate the care plan and services that the patient will receive before, during, and after the transition. You should ensure that the care plan is aligned with the patient's needs, preferences, and goals, and that it is updated and revised as needed. You should also coordinate the services that the patient will need, such as referrals, appointments, transportation, equipment, or home care, and confirm their availability and accessibility.

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Shipe H.

To truly master a skill, one must be a forever student of it.
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Throughout my various roles in healthcare, I have witnessed the entire patient journey…from hospital admission to discharge to rehab, SNF and home with services. The majority of the time it is rushed, there is minimal communication or explanation. The individual is usually not well and recovering, the family (responsible parties) are overwhelmed and confused. They usually do not fully understand insurance coverage for home services or durable medical equipment. This is people that have advocates…someone there helping and providing support. Imagine the ones that are elderly, disabled, alone and do not have the support. The communication and knowledge provisions to ensure understanding are vital and typically in reality there is none.

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4 Monitor and evaluate the transition process and outcomes

Monitoring and evaluating are important steps to ensure the quality and safety of care transitions. You need to monitor and evaluate the transition process and outcomes, and identify any issues or gaps that might arise. You should use indicators and measures that reflect the patient's experience, satisfaction, and health status, as well as the care team's performance and efficiency. You should also provide feedback and follow-up to the patient and the care team, and implement any improvements or changes as needed.

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5 Use technology and innovation

Technology and innovation can help you manage care transitions more effectively and efficiently. You can use technology and innovation to enhance communication, collaboration, coordination, monitoring, and evaluation. For example, you can use electronic health records, telehealth, mobile apps, or web-based platforms to share information, provide education, deliver services, or collect data. You can also use technology and innovation to support patient engagement, empowerment, and self-management.

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Rebecca Albert

Results-driven Cross-Sector Connector
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YES! Technology and sharing of information can help to remove the burden that is often placed on patients. When patients are asked to complete multiple forms with the same or similar questions across providers it becomes overwhelming, frustrating, and may even lead to additional trauma. Multidirectional communication is beneficial to the patients and providers. It also helps to coordinate care and ensure patients are actually connecting to the services needed.

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6 Learn and update your skills and knowledge

Managing care transitions is a complex and dynamic task that requires constant learning and updating of your skills and knowledge. You need to learn and update your skills and knowledge on the best practices, standards, and innovations in care transitions. You should also learn and update your skills and knowledge on the specific needs, preferences, and goals of your patients, as well as the resources and services available in your community. You can use various sources and methods to learn and update your skills and knowledge, such as training, mentoring, networking, or research.

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7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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Lindsay Chapman, LCSW, CCTP

Therapist and Clinical Supervisor Certified Clinical Trauma Professional
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I think it's important to acknowledge the hardship of transitions for the client. As a practitioner, I transition clients all the time, but each client has an individual reaction to how their case will move forward. We should give space for clients to voice these difficulties and listen with sincere ears and offer insight to their strengths and abilities to transition.

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Case Management

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How do you manage patient care transitions?

1

2

3

4

5

6

7

1 Assess the patient's needs and preferences

2 Communicate and collaborate with the care team

3 Coordinate the care plan and services

4 Monitor and evaluate the transition process and outcomes

5 Use technology and innovation

6 Learn and update your skills and knowledge

7 Here’s what else to consider

Case Management

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How do you manage patient care transitions?

1

2

3

4

5

6

7

1 Assess the patient's needs and preferences

2 Communicate and collaborate with the care team

3 Coordinate the care plan and services

4 Monitor and evaluate the transition process and outcomes

5 Use technology and innovation

6 Learn and update your skills and knowledge

7 Here’s what else to consider

Case Management

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