What is Transitions Care?

Document created by adawkins Employee on Jan 12, 2017Last modified by alawson on Mar 27, 2017
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When you get discharged from the hospital, you are given instructions on care, prescriptions and follow-up appointments, and this can be very overwhelming. If those papers are lost, what would you do? You could try to call the hospital and ask for them again, but what if you get lost in the shuffle and there is a breakdown in communication?

A Transitions model was developed targeting chronically ill patients to ensure care continuity/compliance and develop a plan with the patient to help prevent bad outcomes and reduce hospital readmissions.

What this looks like:

  • The RN “hospital coach” screens for patient eligibility in hospital, 
  • The hospital coach talks with patient and explains program; 
  • The patient agrees to enrollment;
  • The hospital coach visits patient daily until discharge;
  • The patient returns home or to rehab;
  • The RN “home coach” visits the patient within 48 hours of discharge;
  • Depending on the risk factors, the patient will have up to five weekly visits and one phone call from home coach;
    • The home coach will provide medication reconciliation.
    • The home coach will ensure follow-up appointments have been made for the patient.
    • The home coach will provide education on care at home, diet and safety for the patient and family caregiver.
  • The home coach will develop a triage plan with the patient on what to do if signs/symptoms of worsening condition appears; and 
  • The home coach is available by phone for any questions.
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