Question

Describe the improvements and opportunities created by the transition. Relate barriers and difficulties encountered during the transition. How has all of this impacted the HIM role in the healthcare facilities?

Answer 1

Transitional care has been defined as a set of actions designed to ensure the coordination and continuity of healthcare as patient's transfer between different locations or different levels of care in the same location.

IMPROVEMENTS IN TRANSITION CARE

• MULTIDISCIPLINARY COMMUNICATION, COLLABORATION AND COORDINATION - INCLUDING PATUENT/CARE GIVER EDUCATION - FROM ADMISSION THROUGH TRANSITION
• CLINICIAN INVOLVEMENT AND SHARED ACCOUNTABILITY DURING ALL POINTS OF TRANSITION
• COMPREHENSIVE PLANNING AND RISK ASSESSMENT THROUGH OUT HOSPITAL STAY
• STANDARDIZED TRANSITION PLANS, PROCEDURES AND FORMS
• STANDARDISED TRAINING
• TIMY FOLLOW-UP, SUPPORT AND COORDINATION AFTER THE PATIENT LEAVES A CARE SETTING
• IF A PATIENT IS READMITTED WITHIN 30 DAYS, GAIN AN UNDERSTANDING OF WHY
• EVALUATION OF TRANSITION OF CARE MEASURES

BARRIERS OF INEFFECTIVE TRANSITION

1. COMMUNICATION BREAKDOWN - care providers do not effectively or completely communicate important informations among themselves, to the patient or to those taking care of the patient at home in a timely fashion.
2. PATIENT EDUCATION BREAKDOWN - patients or family/friend care givers sometimes receive conflicting recommendations, confusing medication regimens and unclear instructions about follow-up care. Patients and caregivers are sometimes excluded from the planning related to the transition process.
3. ACCOUNTABILITY BREAKDOWN - in many cases, there is no physician or clinical entity that takes responsibility to assure that the patient's health care us coordinated across various settings and among different providers. Primary care providers are sometimes not identified by name, and there is limited discharge planning and risk assessment.