Transitions of Care: Let’s Stop Calling Them Hand-offs

Hospitals work very hard at keeping patients safe. Yet across the continuum of care, no where are patients more vulnerable than at transition points, when they move from one level of care to another. The potential for poor outcomes following a transition is frightening: discharging patients to another facility that is not prepared to their medical needs, or sending them home without adequate instruction and resources, can land them in the emergency department, sicker than ever. Adverse events are far too common at transitions of care, mainly due to a lack of communication and coordination between providers.

For this reason, an issue brief from the Commission for Case Manager Certification (CCMC) suggests that we stop referring to these transitions of care as “handoffs,” a word that may imply we are thoughtlessly relinquishing responsibility.

The brief states, “The current emphasis on coordinated care has heightened awareness of the need for smoother transitions, while calling attention to the lack thereof.” Furthermore, it calls for certified case managers to be part of the solution.

Transitions of care are often addressed through the discharge planning process, whether patients are discharged to their home or to another type of care facility. Today, various industry trends are making it necessary for hospitals to re-assess their discharge policies. For one thing, an aging patient population and shorter hospital stays can mean patients go home sicker. And with the new Medicare policies for high readmission rates, the discharge planning process has become vital to a hospital’s financial sustainability. As a result, the trend in discharge planning is moving toward evidence-based policies and a multi-disciplinary approach.

The success of a team-based approach, however, depends on the effectiveness of the team leader, which in many cases is a nurse case manager. For this reason, the Case Management Society of America (CMSA) has created a new certification focused on skills needed to manage transitions of care.

Until now, care transitions haven’t been part of health care education and training – so the fact that transition planning is suddenly being recognized as a specialty may soon translate into expanded job opportunities for those pursuing a career in case management. In fact, a 2010 survey by the Healthcare Intelligence Network revealed that 85 percent of responding hospitals had identified a need for a standardized transition planning program. Almost 76 percent said that they require their transition team leader to be trained in chronic disease management.

Transitions of care should be seamless. In an increasingly complex and often fragmented health care industry, patients have the right to expect they won’t be abandoned or “handed off” without proper instruction, resources and follow-up care.

If you have an interest in working closely with patients, their families, and their care teams to develop a personalized transitional care path, you might consider a career in case management. The perfect way to build the skills you need is through American Sentinel’s online RN-to-MSN program with a specialization in case management. American Sentinel University is an innovative, accredited provider of online nursing degrees that can empower you with knowledge and help you reach your career goals.

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