Transitional care

During transitions, patients with complex medical needs, primarily older patients, are at risk for poorer outcomes due to medication errors and other errors of communication among the involved healthcare providers and between providers and patients/family caregivers. Most research in the area of transitional care has studied the transition from hospitalization to the next provider setting – often a sub-acute nursing facility, a rehabilitation facility, or home either with or without professional homecare services. Adverse patient outcomes include continuation or recurrence of symptoms, temporary or permanent disability, and death. Healthcare utilization outcomes for patients experiencing poor transitional care include returning to the emergency room or being admitted to the hospital. As healthcare expenditures rise at an unsustainable rate, there is increasing focus by patients, providers, and policymakers on restraining unnecessary resource utilization such as that incurred by preventable re-hospitalizations. Transitional care or transition care also refers to the transition of young people with chronic conditions into adult-based services. Transition care is a Youth Health service. As children mature into young adults, they outgrow the expertise of children’s services (paediatrics) and need to find an adult health service that suits them. A program in Australia GMCT Transition Care is an initiative aimed at improving continuity of care for young people with chronic health as they move from children's (paediatric) to adult health services. ==Continuity of health care==

Continuity of health care (also called continuum of care) is to what degree the care is coherent and linked, in turn depending on the quality of information flow, interpersonal skills, and coordination of care. Continuity of health care means different things to different types of caregivers, and can be of several types: • Continuity of information. It includes that information on prior events is used to give care that is appropriate to the patient's current circumstance. Patient safety is increased by understanding and reinforcing health care providers' normal ability to bridge gaps. ==Measuring quality of transitional care==

Care Transitions Measure The only currently nationally endorsed measure of transitional care quality is the Care Transitions Measure (CTM), which is a 15-item survey for administration to patients after discharge from the hospital. The measure also exists as a 3-item survey. Patient responses to the survey predicts return to the emergency department and/or hospital. Dr. Eric Coleman and his team at the University of Colorado at Denver and Health Sciences Center developed the CTM, as well as an intervention designed to improve patient outcomes during transitions. ==Improving quality of transitional care==

After leaving a particular care setting, older patients may not understand how to manage their health care conditions or whom to call if they have a question or if their condition gets worse. Poorly managed transitions can lead to physical and emotional stress for both patients and their caregivers. During a transition, the patients' preferences or personal goals in one setting may not be passed on to the next setting. This may result in important elements of the care plan "falling through the cracks". Ideally, every patient's primary physician would be responsible for the patient through every health care process at all times, but this has been regarded as practically impossible, and, in reality, more effort must rather be put into making transitions more effective. Nevertheless, it has been clearly demonstrated that longitudinal, personal continuity with a general practitioner reduces the need for out-of-hours services and acute admissions to hospital. Furthermore mortality is lowered. The associations are dose dependent and probably causal. Care Transitions Intervention The Care Transitions Intervention (CTI) is a coaching intervention to assist patients in resuming self-care following a change in health status. It uses coaching techniques to ensure that patients are comfortable in managing their own medications and their own health information, understand the signs and symptoms that should lead them to contact a healthcare provider, and have assertion skills to ask important questions of providers. Although the coaching intervention occurs for the first 30 days following the transition, this approach has been shown to significantly reduce hospital readmission as far out as six months. In 2002, the University of Colorado Denver implemented a program called Care Transitions Intervention®. As part of the program, a Transitions Coach works directly with patients and family members for 30 days after discharge to help them understand and manage their complex postdischarge needs, ensuring continuity of care across settings. Participants in the program have a 20 to 40 percent lower hospital readmission rate at 30, 90, and 180 days postdischarge. ==Turfing==

Turfing is where a healthcare provider transfers a patient they could have taken care of to another provider in order to reduce their own patient load. According to one study in the US, nine percent of physicians admitted that they had transferred a patient in such manner. ==See also==