Transitional Care In Health Care What is Transitional Care
Transitional care refers to the care and services necessary for the safe and timely movement of patients from one level of care to another or from one type of healthcare setting to another (Brooten, 1993). Transitional environments encompass hospitals, homes, nursing homes, rehabilitation centers, and hospices. Some authors distinguish subacute care from transitional care, while others use the terms interchangeably.
Those who differentiate between the two view subacute care as a unit or component of inpatient care within an acute care facility, skilled nursing facility, or a standalone medical or rehabilitation center.
Ideally, transitional care concludes with the patient returning to normal functioning and recovery, achieving functional independence, or stabilizing their condition (Brooten). For many frail children or adults, transitional services culminate in long-term care.
Features of Transitional Care
Key features of transitional care include comprehensive discharge planning from one care site to another, coordination of post-discharge services, provision of short-term in-home services, and continued healthcare follow-up.
The most critical components of transitional care services are:
- Continuity of care across different care sites
- Effective communication of the care plan among various providers
- Aligning patient needs and knowledge with the skills of care providers
Transitional care services have grown significantly over the past 10 to 15 years in response to changes in healthcare delivery, particularly the trend towards earlier hospital discharges.
Issues in Transitional Care
Research issues in transitional care involve determining the nature and duration of services required, identifying risk profiles of patients needing these services, defining the type and level of providers necessary, and evaluating the cost-effectiveness of transitional care compared to alternative services.
The duration of transitional services should be tailored to the specific needs of patients or patient groups rather than being dictated by reimbursement plans. However, there is currently no data available that demonstrates the most effective and cost-efficient endpoint for services to achieve optimal patient outcomes in specific patient groups or subgroups.
Vulnerable Groups for Transitional Care
It is widely acknowledged that vulnerable groups such as the elderly, technologically dependent individuals, the disabled, and certain high-risk infants and children should receive transitional services.
Decisions about which patients should receive these services are currently based on factors such as the patient’s functional ability, available caregivers at home, ethnicity, age, previous hospitalizations, and technology dependency.
Types and Levels of Transitional Care
There is considerable variation in the types and levels of transitional care providers, and there is ongoing debate about who should deliver this care. Whether Advanced Practice Nurses (APNs) are necessary for transitional services across all patient groups has yet to be determined.
Home care provided by professional nurses (RNs) has been reported to reduce the negative psychosocial impact on parents caring for medically fragile children at home. Improved patient outcomes through RN-provided home care have also been documented for ventilator-dependent children, oncology patients, and the elderly.
Effectiveness of Transitional Care
Data on the cost-effectiveness of transitional care compared to alternative care approaches are still needed. While some studies have calculated the direct costs of transitional care, costs related to preventing rehospitalizations, acute care visits, increased employment, and the burden on family caregivers are less well documented. These data are crucial for assessing the overall cost benefit or cost-effectiveness of transitional services.
Transitional care services are delivered through public agencies, private non-profit agencies, freestanding and privately operated proprietary agencies, freestanding and hospital-based for-profit agencies, and dedicated units or departments within hospitals.
These services are provided by community nursing services, hospital home care services, Health Maintenance Organization (HMO) follow-up services, and subacute care units established within hospitals or skilled nursing facilities, or as freestanding subacute care hospitals.
Community Health Nursing and Transitional Care
Community or public health nurses have historically provided home follow-up to high-risk patients with complex health needs. Their services are well-recognized and accepted by the general public and healthcare providers. However, over the past 10 to 15 years, budget cuts for community nursing services have nearly eliminated home follow-up services for many patient groups.
Current challenges for community nursing services include:
- Updating the specialty knowledge and skills of agency nurses who have a generalist background
- Maintaining continuity of patient care from the hospital to the home
- Providing sufficient services to ensure good patient outcomes as insurers reimburse for fewer services
As the reimbursed length of stay for even high-risk patients decreases, hospitals’ need for improved discharge planning and post-discharge home care services for these groups increases.
Documented discharge planning is mandatory for hospitals, and many have employed discharge planners to facilitate earlier discharges. Some hospitals contract with community nursing services or independent home care agencies to provide home care services for their high-risk patients. An increasing number of hospitals are establishing their own home care services.
HMOs have a clear financial incentive to discharge patients early and prevent costly rehospitalizations. They have employed case managers and nurses with specialized knowledge and skills to assess patients’ discharge and home care needs. Because profitability is essential for for-profit HMOs, their approach emphasizes minimal hospital stays and post-discharge services.
Home follow-up services vary in the number of visits provided, the type of nurse provider (generalist or specialist), and the length of follow-up. More than the routinely allowable number of home visits may be reimbursable for a patient, but this must be negotiated between the provider and the insurer.
Future of Nursing Research and Transitional Care
Research is needed to determine:
- The nature, intensity, and duration of transitional services required to optimize patient and family outcomes
- The profiles of patients who would benefit most from these services
- The types and levels of providers needed to deliver these services
- The costs associated with such services
Ongoing study of existing and emerging models of transitional care is also necessary to identify which models achieve the highest quality and most cost-effective outcomes.
Study findings suggest that for specific patient groups or subgroups, discharge planning and home care protocols tailored to their unique needs are more effective than the general protocols currently used by many hospitals and home care agencies.
Targeted protocols should be derived from empirical data regarding:
- The nature of patients’ and caregivers’ needs (e.g., lack of knowledge, complexity of therapeutic regimens)
- Strengths (e.g., supportive family) or barriers (e.g., language) to meeting needs
- Timing of needs (e.g., 24 hours after discharge)
- The most cost-effective strategies to meet needs (e.g., telephone contact vs. home visits)
- The length of follow-up required
Unfortunately, for many patient groups, the research base is limited. For these groups, research efforts should first focus on identifying the needs of patients and caregivers, followed by designing and testing interventions to meet those unique needs.
There is a need for studies that compare and contrast existing and emerging models of transitional care, focusing on differences in both processes and outcomes of care.
Knowledge generated from studies of these models would contribute to the ongoing discussion and debate about which providers are most effective and efficient in coordinating transitional care services and ensuring continuity of care for patients and their caregivers. Study findings would also advance our understanding of effective ways to engage a multidisciplinary team of providers in transitional services.
Finally, the knowledge generated from this research would help determine the care processes that existing data suggest are crucial for positive patient outcomes, including assessing, communicating, clinical decision-making, teaching, collaborating, referring, monitoring, and evaluating.