81:
27:, between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. For young people the focus is on moving successfully from child to adult health services.
57:
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.
174:
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
165:
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
144:
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
47:
facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the
157:
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.
56:
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
186:
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.
60:
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
175:
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
34:
defines transitional care as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to)
95:) 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:
198:
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.
48:
patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.
166:
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.
158:
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".
146:
105:
Continuity of personal relationships, recognizing that an ongoing relationship between patients and providers is the undergirding that connects care over time and bridges discontinuous events.
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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
208:
367:
461:
Coleman EA (April 2003). "Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs".
72:
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.
525:"Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway"
609:
64:
Transitional care or transition care also refers to the transition of young people with chronic conditions into adult-based services. Transition care is a
234:
704:
102:. It includes that information on prior events is used to give care that is appropriate to the patient's current circumstance.
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Participants in the program have a 20 to 40 percent lower hospital readmission rate at 30, 90, and 180 days postdischarge.
374:
183:
112:
To avoid misinterpretation, the type of continuity should be agreed to before any related discussions or planning begin.
31:
443:
116:
refers to an optimal situation where there is continuity in the healthcare even in the presence of many transitions.
242:
90:
123:
usually reveals the presence of many gaps in health continuity, yet only rarely do gaps produce accidents.
99:
149:
developed the CTM, as well as an intervention designed to improve patient outcomes during transitions.
176:
128:
486:
680:
505:
256:
Martin MA, Press VG, Nyenhuis SM, Krishnan JA, Erwin K, Mosnaim G, et al. (December 2016).
610:"Transition Coaches Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs"
661:
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478:
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339:
287:
162:
651:
643:
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unnecessary resource utilization such as that incurred by preventable re-hospitalizations.
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69:
656:
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524:
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282:
257:
124:
44:
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309:
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Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R (November 2003).
698:
647:
474:
120:
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258:"Care transition interventions for children with asthma in the emergency department"
65:
40:
23:
during a movement from one healthcare setting to either another or to home, called
580:
235:"Improving the Quality of Transitional Care for Persons with Complex Care Needs"
20:
273:
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the emergency department and/or hospital. Dr. Eric
Coleman and his team at the
447:
325:
213:
411:
665:
558:
540:
482:
429:
343:
291:
681:"Doctors Admit to Unprofessional Behavior in Study at 3 Chicago Hospitals"
368:
Defusing the
Confusion: Concepts and Measures of Continuity of Healthcare
36:
373:(Report). Canadian Health Services Research Foundation. Archived from
444:"Care Transitions Project, Health Care Policy and Research, Measures"
595:
523:
Sandvik H, Hetlevik Ø, Blinkenberg J, Hunskaar S (February 2022).
79:
396:"Gaps in the continuity of care and progress on patient safety"
43:, the patient’s home, primary and specialty care offices, and
147:
University of
Colorado at Denver and Health Sciences Center
612:. Agency for Healthcare Research and Quality. 2013-04-10
573:"Supporting Providers in Improving Transitional Care"
446:. University of Colorado Hospital. Archived from
241:. The American Geriatrics Society. Archived from
310:"Continuity of care: a multidisciplinary review"
209:System of concepts to support continuity of care
303:
301:
262:The Journal of Allergy and Clinical Immunology
127:is increased by understanding and reinforcing
366:Reid R, Haggerty J, McKendry R (March 2002).
19:refers to the coordination and continuity of
8:
52:Defining and understanding transitional care
361:
359:
357:
355:
353:
463:Journal of the American Geriatrics Society
394:Cook RI, Render M, Woods DD (March 2000).
389:
387:
233:AGS Health Care Systems Committee (2006).
655:
548:
419:
333:
281:
529:The British Journal of General Practice
225:
88:Continuity of health care (also called
153:Improving quality of transitional care
135:Measuring quality of transitional care
84:Lake Taylor Transitional Care Hospital
630:Stern DT, Caldicott CV (April 1999).
30:A recent position statement from the
7:
636:Journal of General Internal Medicine
577:Colorado Foundation for Medical Care
506:"Continuity of Care Starts With You"
632:"Turfing: patients in the balance"
108:Continuity of clinical management.
14:
131:' normal ability to bridge gaps.
648:10.1046/j.1525-1497.1999.00325.x
475:10.1046/j.1532-5415.2003.51185.x
705:Types of health care facilities
596:"The Care Transitions Program"
1:
184:University of Colorado Denver
170:Care Transitions Intervention
39:, sub-acute and post-acute
32:American Geriatrics Society
721:
504:Warth GJ (21 April 2011).
274:10.1016/j.jaci.2016.10.012
179:as far out as six months.
326:10.1136/bmj.327.7425.1219
161:Ideally, every patient's
100:Continuity of information
76:Continuity of health care
412:10.1136/bmj.320.7237.791
140:Care Transitions Measure
541:10.3399/BJGP.2021.0340
85:
687:– via MedScape.
129:health care providers
83:
177:hospital readmission
70:GMCT Transition Care
679:Rau J (June 2012).
450:on 20 October 2007.
320:(7425): 1219–1221.
245:on 2 February 2007.
685:Kaiser Health News
239:Position Statement
86:
406:(7237): 791–794.
380:on 11 March 2012.
163:primary physician
17:Transitional care
712:
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579:. Archived from
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535:(715): e84–e90.
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268:(6): 1518–1525.
253:
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583:on 7 July 2011.
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25:care transition
12:
11:
5:
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642:(4): 243–248.
622:
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469:(4): 549–555.
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125:Patient safety
121:medical errors
110:
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77:
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53:
50:
45:long-term care
13:
10:
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182:In 2002, the
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114:Seamless care
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41:nursing homes
38:
33:
28:
26:
22:
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684:
674:
639:
635:
625:
614:. Retrieved
604:
594:Coleman EA.
589:
581:the original
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567:
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448:the original
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375:the original
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243:the original
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119:Analysis of
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66:Youth Health
63:
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29:
24:
16:
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21:health care
616:2013-05-10
220:References
214:GP Liaison
91:continuum
37:hospitals
699:Category
666:10203637
559:34607797
510:Medscape
491:20072076
483:12657078
430:10720370
344:14630762
292:27931533
203:See also
657:1496571
550:8510690
421:1117777
283:5327498
196:Turfing
191:Turfing
93:of care
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335:274066
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487:S2CID
378:(PDF)
371:(PDF)
662:PMID
555:PMID
479:PMID
426:PMID
340:PMID
288:PMID
652:PMC
644:doi
545:PMC
537:doi
471:doi
416:PMC
408:doi
404:320
400:BMJ
330:PMC
322:doi
318:327
314:BMJ
278:PMC
270:doi
266:138
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