Tips on Creating a Smooth Patient Care Transition

The chaos that is hospital care can sometimes cause undue stress for patients, nurses, and doctors alike. Office managers and care coordinators do a lot to alleviate some of the pressures of employees, but nurses are still the primary advocates for patients. They are the go-to team for information and assistance. As the first line of defense and closest contact with patients, it is absolutely vital that nurses put in effort to make the patient care transition as smooth as possible.

What is the Care Transition?

A patient will likely see several different healthcare professionals during the term of their illness or health problem. They may go from a nurse to an anesthetist to a surgeon. Or they may go from being in the hospital with pneumonia one month and back in again with a heart problem the next. In other words, patients are going to be dealing with a lot of different people and there is a lot of information that needs to be carried over during those transitions. Missing information can lead to mistakes which could lead to costly problems, both for the patient and the provider.

How to Make the Transition Better

  1. Talk to the patient and their family. The people involved should be aware of the plan of care that will take place. The information should be thorough and easy to understand. If you aren’t sure if they understand completely, ask questions to get clarification. Do your best to relay every bit of information, even if it seems obvious to you. Everything from skincare to toileting should be addressed if it is relevant to the situation. If a patient has the information, they have a bit more control over their own situation.
  2. Keep relevant documentation. On the patient’s health records and even your own list, there should be documentation of any diagnoses that have been made for the patient and what procedures have been completed for them. The more accurate and thorough the list, the less likely it is that the next person in charge of patient care will make any mistakes.
  3. Pay attention to medications. If the patient is taking any medication, make sure this is documented. During the transition, the medications should always be reconciled and new medications need to be checked for possible interactions. You should also match generic to brand name medications for instances in which insurance will only cover a certain option. Remember, the more people and items are involved in the transition, the more careful you have to be.
  4. Know what happens next. Even though you may be “passing off” your patient to the next in line responsible for their care, you should know what the next step in that care is. Requesting documentation of what will happen in the next step will help you decide how to finish your own treatment of the patient and will help them know what to expect in the near future. Aspects like treatments, therapies and any necessary equipment, diet, and exercise should all be addressed before the transition is complete. This will allow you to make sure that the care they are receiving now will allow for a smooth transition to the next phase of treatment.
  5. Follow-up information. Your patient should be very clear on when and where their next follow-up treatment will occur. Knowing when they are next expected to be present will help them stay on track with their care transition. During this phase you should also be aware of who should be called if there is a problem with the follow-up appointment.

Final Thoughts

Patient care transitions can be challenging to navigate, but with the above steps, you should be able to make it as smooth as possible. As long as you are realistic about expectations and ensure a support system for your patient, you should see a reasonable transition.