Health Care Transitions Must Be Patient-Centered

By David Farrell

Care transitions are defined as movement of patients between providers such as when an elder moves from the hospital to a nursing home – or from the nursing home to their home with a home health care agency.  
Care transitions can be dangerous, especially for frail elders with complex chronic conditions.  Too often, care transitions are poorly executed, increasing healthcare costs, and often resulting in readmission back into the hospital.  
In fact, according to the Institute for Healthcare Improvement, there are about five million hospital readmissions every year, with approximately a third occurring within 90 days of discharge, of which 46% could be prevented.
Many patients make multiple transitions across various healthcare settings.  With each transition, the risks associated with poor care coordination and communication between healthcare providers increases.  In many cases, patients and their family members are not prepared to cope with care transitions, nor do they have the competence to navigate a fragmented healthcare system and advocate on their own behalf.
At its core, a safe transition results from a patient-centered process.  The patient, caregivers and families must be embraced as partners of the care team.  They are to be empowered with education, decision-making and choices, including end-of-life care.  
In addition, care transitions should be provided in a manner compatible with the patient’s cultural health beliefs, preferences, literacy level, practices and preferred language.  Again, this is no easy task.  For all providers across the continuum in Oakland, it means adopting new patient-centered approaches, stepping up communication across settings of care and managing internal system change.
Social and financial issues dominate the barriers to improving care transitions.  On the social side, the solution relies heavily on the patient and their primary caregiver, usually a family member.  To keep people safe at home and avoid re-hospitalization and multiple transitions, patients and their family caregivers must learn to use a personal health record, arm themselves with checklists of good questions to ask about their medications before office visits and learn to manage their own complex health conditions.
At Windsor Healthcare Center of Oakland, we routinely follow-up with each patient we discharge home by calling each one within 24-48 hours after discharge.  We make sure they are safe, have filled their prescriptions, scheduled their next doctor’s appointment and ensure that they understand their medications.
For more information on Windsor, go to
David Farrell, MSW, LNHA, is Regional Director of Operations at Windsor Healthcare Center of Oakland.

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