Let’s start by answering the basic question, “what is transitional care?” In simple words, transitional care refers to the procedures involved in transferring a patient from one care setting (hospital, nursing home, SNF, assisted living facility, primary care physician, etc.) to another as safe and seamless as possible. When it comes to patient transfers, every minute counts.
For a patient transfer to be effective and secure, the entire process should be made timely and efficient, right from when a transfer is initiated to when the patient is located at the right place with the right level of care.
Effective communication forms the core of a successful patient transfer, particularly if a patient is transferred between different health systems. Any gaps in communication can lead to arduous patient transfers that can significantly impact safety and quality. So, how do you ensure better support, and safe transfers, for improved patient outcomes?
The Consequences of Poor Transitional Care
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Transitional care isn’t a single-step process. Instead, it involves a wide array of time-limited services, complex care coordination processes, and interdependencies between settings, like health care, social care, housing support, and the voluntary sector, designed to promote continued care and safe transfer of patients from one healthcare setting to another.
The reason why a lot of healthcare facilities focus on transitional care is that transition is a vulnerable point in every patient’s life. When implemented well, transitional care minimizes the need for hospital readmissions and ensures patients receive the support they need whenever and wherever they need it. This includes interventions that support the elderly, people with complex or long-term needs, those with mental health problems, and more.
On the other hand, poorly managed patient transfers can lead to people experiencing fragmented care and unmet needs as they journey through your healthcare system. Furthermore, there also arise chances of delayed transfers and greater pressure on acute services, which indicates the inaccessible social care packages, inadequate capacity of community services, and poor communication between care providers.
How To Ensure Seamless Transitional Care For Patients
An important aspect of transitional care is quickly responding to transfer requests. However, healthcare professionals are anything but busy. So, some mechanisms should streamline communication among physicians, clinicians, and administrative and clinical staff.
Additionally, it should also help all team members involved in the patient transfer have access to the same, up-to-date patient information. This is where electronic health records (EHRs) can be of immense help.
A Complex Transferal
Most of the time, patients requiring transfers have complex health issues. So, admission to a new healthcare facility will depend on whether or not the institution can accommodate its unique needs. Therefore, every healthcare professional involved in the handoff must have access to the same patient information so they can coordinate the right care, in the right setting, at the right time.
Similarly, staff shortages are a real challenge for health systems and hospitals that aims to dedicate the right staff to a specific patient transfer process. The pandemic worsened this problem by keeping numerous staff members constantly on the phone, making calls within and outside their health systems to find the right placement for a patient who must be transferred.
Asking the Right Questions
This sheds light on the importance of dedicated staff who understand the complexities of the patient transfer process. Meaning people who know the right questions to ask and the proper steps to take so they can alleviate administrative burdens from staff members who should be more focused on direct patient care.
So, a centralized process is essential for the smooth transfer process and helps staff members save time, stress, and resources. Furthermore, teams involved in patient transfers should be educated and trained on where to find the most up-to-date information and when and how to update it, so it is readily available for everyone involved in the transfer process. Simply put, they should be familiar with EHRs and how to leverage them efficiently.
To achieve this, consider having healthcare professionals take part in conferences or exhibitions, like the HIMSS conference. HIMSS’s primary goal is to empower digital health ecosystems by offering world-class education for thought leaders in healthcare.
Make Transitional Care Seamless, Safe, And Efficient
Depending on a patient’s unique situation, you might have weeks or months to plan their transfer to a different care facility. Or, you might have just a day or two. Regardless of when you begin the process, ensure you have everything necessary to make the transfer safe beforehand.
This includes an efficient EHR solution, knowledgeable professionals, and a centralized approach. With all these tools in hand, you will be able to reduce the risk of hospital readmissions and weave better patient outcomes.
