Best practices for safe (and successful) care transitions

Foundations for safe care transitions

The Joint Commission (TJC) names seven foundations for safe, effective patient care transitions from acute care to another healthcare setting. These foundations help build best practices for all nurses, regardless of practice area:

1. Early identification of patients at risk
2. Leadership support
3. Medication management
4. Multidisciplinary collaboration
5. Patient and family action/engagement
6. Transfer of information
7. Transitional planning

Putting these foundations into practice helps reduce readmissions and decreases emergency room visits. Patients are also more likely to give high satisfaction scores and be more compliant with their care plans. And caregiver competence is improved when these foundations are used during the transition process.

Care transition best practices

For a safe patient transition to occur, each member of the care team must be committed to:

• Participating fully in the transition
• Using the latest evidence-based practices to complete the transfer of care.

As a nurse, your role in care transitions should focus around six best practices:

1. Perform an assessment: You already know how important your nursing assessment is to the patient’s care plan. Regularly assessing your patient during a care transition is key to successfully maintaining continuity of care. An assessment also helps get your patient onboard with their transfer, identifying their concerns and educational needs, and highlighting the advantages and disadvantages of the transition.
2. Help manage the transfer: If your care transition isn’t managed well, the likelihood for readmission grows. Each member of the interdisciplinary care team must understand their unique role during the transition. You can help by identifying role responsibilities (such as medication reconciliation), communicating with other healthcare team members, and promoting patient participation in the transition.
3. Communicate: Good communications skills are absolutely essential for safe patient care transitions. Help enhance communication among the team by using care plans and organizational care pathways, including standardized hand-off information. Be sure to share information with your patient too with regular follow-ups and accurate, timely information.
4. Consider comprehensive care models: Your organization can help make patient care transitions more effective by developing and implementing care models for each type of transfer. These models formalize roles among the interdisciplinary team. Additionally, team members follow standardized processes through with information is gathered and patient care is administered.
5. Keep your patient in mind: It seems obvious, but the needs of your patient should be kept in mind during the entire transitional experience. Nurses are in prime position to know exactly what a patient needs to make a transfer successful. As a nurse, you can determine how ready your patient is to make the transfer, what they need to learn to be successful, and how receptive they are to additional information and the transfer itself.
6. Identify (and overcome) patient knowledge barriers: Many patients don’t understand just how different their care will be once they leave acute care. Some patients fear being alone, while others fear having caregivers come to their homes to help them. Working to identify your patient’s needs and barriers to success helps you implement strategies designed to promote their comfort and receptibility to care.