Transition of Care Management

What Is Transition of Care Management?

Transitions of Care refer to the movement of patients between healthcare locations, providers, or different levels of care within the same location, as their conditions and care needs change.

Key Elements

• Discharge planning.
• Medication reconciliation.
• Timely provider access.
• Timely post-discharge follow-up visits.
• Facility access to care and services needed.

Goals

• Improve patients, their family’s, and their caregiver’s participation in healthcare decisions and management.
• Improve ability to self-manage health conditions, medication adherence, and participation in health promotion activities.
• Assist in proactive monitoring, evaluation, and problem-solving.
• Improve collaboration among and between the patient, their family, their caregiver, and their provider(s).
• Improve the coordination and continuity of care across the continuum of care.
• Improve the patients, their family’s, and their caregiver’s health status, satisfaction, and quality of life.
• Improve the delivery of cost-effective care in the least restrictive environment.
  

Why is Transitional Care Management Important?

Engaging patients beyond the hospital setting and into recovery is critical in reducing complications, avoiding readmission, and understanding the patient recovery process.

• Patients may feel vulnerable and confused post-discharge.
• Patients forget what their care providers told them.
• Patients are confused about which medications to take.
• Patients are frequently prescribed multiple medications and it can be difficult to remember what to take when.

These factors can lead to readmission and adverse events. For more information, contact our Director of Social Services, Shannon Amyotte, LSW, at (701) 776-5455 ext. 2145 or Care Coordinator Robyn Arnold, RN at (701)776-5455 ext. 2391.