BACKGROUND AND STATEMENT OF PROBLEM

A. Definition

Transitional care: The American Geriatrics Society defines transitional care as “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) hospitals, subacute and post-acute nursing facilities, the patient’s home, primary and specialty care offices, and long-term care facilities. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is based on a comprehensive plan of care and includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition” (Coleman & Boult, 2003, p. 549).

Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of healthcare and across care settings (Naylor et al., 2018).

B. Etiology and/or epidemiology

1. Situations likely to result in failed transitions include poor social support, discharge during times when ancillary services are unavailable, uncertain medication reconciliation, depression, and patients’ cognitive limitations (Cumbler et al., 2008).
2. Medication errors related to medication reconciliation typically occur at the “interfaces of care”—when a patient is admitted to, transferred within, or discharged from a healthcare facility (Coleman & Boult, 2003).
3. Hospital discharge practices are placing an increasing burden of care on the family caregiver (Naylor et al., 2014).
4. RCTs of transitional care interventions have been shown to reduce hospital readmissions and healthcare costs (Becker et al., 2021; Coleman et al., 2006; Naylor et al., 2004).
5. APN interventions in transition care have consistently resulted in improved patient outcomes and reduced healthcare costs (Naylor et al., 2004).

PARAMETERS OF ASSESSMENT

A. The patient population that is most likely to benefit from transitional care interventions includes those who are diagnosed with one or more of the following diseases: HF, cognitive impairment, COPD, coronary artery disease, diabetes, stroke, spinal stenosis, hip fracture, peripheral vascular disease, cardiac arrhythmias, DVT, and pulmonary embolism (Coleman et al., 2004).

B. On admission to an acute care setting, starting at the ED, patient evaluation must include referral of vulnerable older adults for transitional care services.

C. Comply with TJC standards in medication reconciliation.

NURSING CARE STRATEGIES

A. A synthesis of best-practice guidelines based on existing TCMs recommends the following key features of a fully developed transition of care (Coleman & Boult, 2003):

1. Multidisciplinary communication, collaboration, and coordination, including patient/caregiver education, from admission through transition
2. Clinician involvement and shared accountability during all points of transition
3. Comprehensive planning and risk assessment throughout the hospital stay
4. Standardized transition plans, procedures, and forms
5. Standardized training of every care provider involved
6. Gaining an understanding of the factors associated with the admission if a patient is readmitted within 30 days
7. Evaluation of transitions of care measures

B. Successful and safe transitions demand active patient and informal caregiver involvement. To improve patient advocacy and safety, the nurse can:

1. Use the teach-back method in all patient education encounters
2. Promote the “Speak Up” initiative by the TJC (2018); the brochure “Planning Your Follow-Up Care” lists patient-centered and safety-focused questions to be asked by the patients of their healthcare provider before they are discharged from the hospital
3. Encourage family involvement and direct them to the “Next Steps in Care” website (see the “Resources” section)
4. Provide the patient with a complete and updated medication reconciliation record, which should include medications the patient was taking before admission, medications during hospitalization, and medications to be continued on discharge (TJC, 2022)
5. Implement evidence-based interventions to reduce transition-related medication discrepancies (Corbett et al., 2010)
6. Encourage the patients to carry a medication list (i.e., a copy of recent medication reconciliation from a recent hospital admission) and to share the list with providers of care, including primary care and specialist physicians, nurses, and pharmacists (TJC, 2022)

C. Critical elements of successful transitions include the following:

1. The 8P Screening Tool recommended by the Society of Hospital Medicine (n.d.) to identify patients at risk for adverse events posthospital discharge (www.hospitalmedicine.org/globalassets/clinical-topics/clinical-pdf/8ps_riskassess-1.pdf)
2. Team approach and preferably nurse-led (APN or specialized nurse; Coleman et al., 2006; Naylor et al., 2004)
3. Active and early family involvement across transitions (Naylor et al., 2018)
4. Proactive patient roles and self-advocacy (Coleman et al., 2006)
5. High-quality and individualized patient and family discharge instructions (Becker et al., 2021)
6. Application of interventions to improve comprehension among patients with low health literacy and impaired cognitive function (Chugh et al., 2009), such as the National Patient Safety Foundation’s “Ask Me 3” campaign
7. Patient and informal caregiver empowerment through education
8. Commencement of interventions well before discharge (Naylor et al., 2018)
9. Elements identified for effective and successful transitions (Coleman, 2003):
   • Communication between the sending and receiving clinicians regarding a common plan of care
   • A summary of care provided by the sending institution (to the next care providers)
   • The patient’s goals and preferences (including advance directives)
   • An updated list of problems, baseline physical and cognitive functional status, medications, and allergies
   • Contact information for the patient’s caregiver(s) and primary care practitioner
   • Preparation of the patient and caregiver for what to expect at the next site of care
   • Reconciliation of the patient’s prescribed medications before the initial transfer with the current regimen and communication of changes to the patient and family
   • A follow-up plan for how outstanding tests and follow-up appointments will be completed
   • An explicit discussion with the patient and caregiver regarding warning symptoms or signs to monitor that may indicate that the condition has worsened and the name and phone number of whom to contact if this occurs

D. Barriers to successful transitions (barriers to effective care transitions have been identified at three levels: the delivery system, the clinician, and the patient; Coleman, 2003) include the following:

1. Delivery system barriers
   • The lack of formal relationships between care settings represents a barrier to cross-site communication and collaboration.
   • The lack of financial incentives promoting transitional care and accountability in fee-for-service Medicare; although such incentives exist in Medicare-managed care, most plans do not fully address care integration.
   • The different financing and contractual relationships that facilities have with various pharmaceutical companies impede effective transitions. As patients are transferred across settings, each facility has incentives to prescribe or substitute medications according to its own medication formulary. This constant changing of medications creates confusion for the patient, caregiver, and receiving clinicians.
   • Neither fee-for-service nor Medicare-managed care has implemented quality or performance indicators designed to assess the effectiveness of transitional care.
   • There is a lack of information systems designed to facilitate the timely transfer of essential information.
   • There is a lack of interoperability of electronic health information.
2. Clinician barriers
   • The growing reliance on designated institution-based physicians (i.e., hospitalists) and productivity pressures have made it difficult for primary care physicians to follow their patients when they require hospitalization or short-term rehabilitation.
   • Nursing staff shortages have forced an increasing number of acute care hospitals to divert patients to other facilities, where a completely new set of clinicians, who often do not have timely access to the patients’ prior medical records, manage them. SNF staff are also overwhelmed and do not have the time or initiative to request necessary information.
   • Clinicians do not verbally communicate patient information to one another across care settings.
   • Clinicians are not familiar with other clinical sites (e.g., sending, receiving).
3. Patient barriers
   • There is lack of advocacy or outcry from patients for improving transitional care until they or family members are confronted with the problem firsthand.
   • Older patients and their caregivers are often not well-prepared or equipped to optimize the care they will receive in the next setting.
   • Patients may have unrealistic expectations about the content or duration of the next phase of care and may not feel empowered to express their preferences or provide input for their care plan.
   • Patients may not feel comfortable expressing their concern that the primary factor that led to their disease exacerbation was not adequately addressed.

E. Evaluation/expected outcomes include the following:

1. Clinician outcomes
   • Increase nurse involvement in leading transition care teams.
   • Enhance staff training of transitional care by a multidisciplinary team.
   • Include patient’s transitional care needs during in-hospital handoff.
   • Improve medication reconciliation throughout all transition interfaces.
2. Patient outcomes (Mitchell et al., 2018)
   • Feeling cared about by medical providers
   • Sensing clear accountability from the health system regarding who is responsible for overseeing their care and who to contact for help
   • Feeling prepared and capable to care for themselves, especially any potential complications
3. Informal caregiver outcomes (Mitchell et al., 2018)
   • Improve informal caregiver satisfaction and exercise proactive roles during transitions across healthcare settings.
   • Increase informal caregiver participation in all transition interfaces.
   • Perceive care as excellent and trustworthy.
4. Institutional outcomes
   • Adopt evidence-based TCMs and provide logistic support.
   • Provide orientation and ongoing education on transitional care strategies.
   • Introduce transitional care content into nursing core curriculum, at both baccalaureate and graduate levels.
   • Assess transition care interventions as part of hospital accreditation by the TJC and the CMS.
   • Explore use of telehealth as an option for transitional care interventions.

FOLLOW-UP MONITORING

A. Institute comprehensive and multidisciplinary transition care planning as soon as the patient is admitted and sustain throughout hospitalization.

B. Identify transition care team members and perform periodic role reassessment, including roles of informal caregivers.

C. Incorporate continuous quality improvement criteria into transition care programs, such as monitoring for rehospitalization of older adults, quality of discharge instruction, and medication reconciliation.

D. Develop ongoing transitional care educational programs for both formal and informal caregivers using high-tech and traditional media.

E. Provide orientation and ongoing education on procedures for reconciling medications to all healthcare providers, including ongoing monitoring (TJC, 2022).

F. Perform periodic debriefing of high-risk discharges as a quality improvement strategy.

G. Improve recognition of condition changes or adverse events caused by medications.

H. Increase patients’ and caregivers’ knowledge concerning actions to take if condition worsens, including contact information.

I. Consistently transmit hospital discharge summary with all the relevant information to primary care providers (Burton, 2012).

J. Use the ACOVE-3 QIs as a guide in assessing, monitoring, and evaluating care of specific conditions (American Geriatrics Society, 2007).

K. Use a decision support algorithm for referrals to postacute care (Bowles et al., 2018).

L. Gauge hospital performance in the HRRP. Measure the hospital’s relative performance and the ratio of predicted to expected readmissions (CMS, 2019b).

RELEVANT PRACTICE GUIDELINES

A. Ongoing chart and medical records review of patients being considered for discharge or awaiting transition should reflect the QI outlined in the ACOVE under the Continuity and Coordination of Care QI heading (Askari et al., 2011).

B. Adopt NPSGs most relevant to transitions of care, such as the domains of improving staff communication and using medicines safely (TJC, 2022). The elements of performance include the following:

1. Obtain information on the medications the patient is currently taking when they are admitted to the hospital or seen in an outpatient setting. This information is documented in a list or other format that is useful to those who manage medications.
   • Current medications include those taken at scheduled times and those taken on an as-needed basis.
   • It is often difficult to obtain complete information on current medication from a patient. A good-faith effort to obtain this information from the patient and/or other sources will be considered as meeting the intent of the EP.
2. Define the types of medication information to be collected in non–24-hour settings and different patient circumstances.
   • Examples of non-24-hour settings include the ED, primary care, outpatient radiology, ambulatory surgery, and diagnostic settings.
   • Examples of medication information that may be collected include name, dose, route, frequency, and purpose.
3. Compare the medication information the patient brought to the hospital with the medications ordered for the patient by the hospital to identify and resolve discrepancies.
   • Discrepancies include omissions, duplications, contraindications, unclear information, and changes. A qualified individual does the comparison.
4. Provide the patient (or family as needed) with written information on the medications the patient should be taking when they are discharged from the hospital or at the end of an outpatient encounter (i.e., name, dose, route, frequency, and purpose).
   • When the only additional medications prescribed are for a short duration, the medication information the hospital provides may include only those medications.
5. Explain the importance of managing medication information to the patient when they are discharged from the hospital or at the end of an outpatient encounter.
   • Examples include instructing the patient to give a list to their primary care physician; to update the information when medications are discontinued, doses are changed, or new medications (including over-the-counter products) are added; and to carry medication information at all times in the event of emergency situations.

C. Implement policies and procedures related to the CARE Act, such as educating caregivers of the medical tasks they will need to perform for the patient at home (Rodakowski et al., 2021).

D. Adopt the 4Ms (What Matters, Medication, Mentation, and Mobility) Age-Friendly Health Systems framework in implementing transitional care programs (see Chapter 45, “Age-Friendly Health Systems”).

ABBREVIATIONS

ACOVE       assessing care of vulnerable elders

APN           advanced practice nurse

CARE         caregiver advise, record and enable Act

CMS          centers for medicare & medicaid services

COPD        chronic obstructive pulmonary disease

DVT           deep venous thrombosis

EP              element of performance

HF              heart failure

HRRP         hospital readmissions reduction program

NPSG         national patient safety goals

QI              quality indicator

RCTs           randomized controlled trials

SNF            skilled nursing facility

TCM           transitional care model

TJC             the joint commission

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 40, Lim, F. (2025) Transitional Care Models