Moving toward better transitional care


Recently it seems that we see or hear this phrase — “transitional care” — in reference to health care, but what does it mean? And more importantly, what does it mean to you and your loved ones?

Let’s start with a simple definition: Transitional care refers to coordinated actions and information shared between health care professionals — such as primary care doctors, specialists and the hospital team — and different locations of care, like a hospital, emergency room, nursing facility or home.

So why is transitional care so important, and why are we hearing about it now? When people move between care settings, there are many opportunities for miscommunication, and the individual may experience decreased quality and poor coordination of care and treatment. Examples may include poor understanding of medications, leading to an error in how those medications are taken, or poor understanding of the disease, resulting in an avoidable hospital trip.

Most of us have personal or family experience with care transitions. Despite how frequently they occur, not much attention has been paid to ensuring the move between health care professionals and settings goes smoothly and safely.

When you think of how much information is involved — including health history, medications, tests, follow-up appointments and plans, education, and coordination — it is no wonder there are so many opportunities for something to be overlooked. Individuals with a chronic illness are even more at risk because of their frequent use of health care services and the many professionals and settings they may use on a regular basis.

Discussion of transitional care is widespread right now for many reasons. Health care reform is of serious concern to our country at this time. Up until recently there has been little incentive to improve transitional care. Recent trends — such as the use of electronic medical records, financial penalties and incentives from Medicare, and quality initiatives — have encouraged a greater focus on improving critical transition times.

Many health care systems and community partners, such as Inova, have implemented transitional care management programs to ease patients’ movement from the hospital to the home setting.

In addition to health care professionals making changes to improve care transitions, patients and their caregivers need to play a significant role in transitional care. They need to ask their health care team: What are the warning signs of their illness? What should they do if they occur? What are the medications? Why are they prescribed and how do they work? And when are follow-up appointments required?

Additionally, patients or their caregivers should bring — and review — medication lists as well as a list of the health care professionals involved with their care to all appointments or locations to prevent errors and improve communication. Don’t assume everyone is communicating with each other. This is your illness, and you have a responsibility to be a part of the management.

Together you and your health care team can improve the coordination of your treatment for the better.
The writer is the director of transitional care at Inova Health System.