Health Care System and Transitional Care
What is Transitional Care,Features of Transitional Care,Issues In transitional Care,Vulnerable Group for Transitional Care,Types and Level of Transitional Care,Effectiveness of Transitional Care,Community Health Nursing and Transitional Care,Future of Nursing Research and Transitional Care.
What is Transitional Care
Transitional care refers to care and services required in the safe
and timely transfer of patients from one level of care to another or from one
type of health care setting to another (Brooten, 1993). Transitional
environments include the hospital, home, nursing home, rehabilitation center,
and hospice. Some authors differentiate subacute care from transitional care;
others use the terms interchangeably.
Those who make the distinction view
subacute care as a unit or component of inpatient care in an acute care
facility, skilled nursing facility, or freestanding medical or rehabilitation
center.
Transitional care ideally ends with normal functioning and recovery,
functional independence, or stabilization of the patient’s condition (Brooten).
In the case of many friar children or adults, transitional services end in long
term care.
Features of Transitional Care
Key features of transitional care include comprehensive discharge
planning from one site of care to another, coordination of post discharge
services, provision of in-home services on a short-term basis, and continued
health care follow up.
The most important components of transitional care
services are continuity of care across sites of care, communication of the plan
of care among the differing providers, and matching patient needs and knowledge
with skills of the care providers.
Transitional care services have increased significantly over the
past 10 to 15 years in response to changes in health care delivery, especially
earlier hospital discharge of patients.
Issues In transitional Care
Research issues in transitional care include determining the nature
and length of the service needed, risk profiles of patients who need the
service, type and level of providers needed, and cost effectiveness of the
service compared to alternative services.
The length of transitional services
should vary with the specific needs of the patients or group of patients rather
than being dictated by the reimbursement plan. However, data are not available
demonstrating the most effective and cost efficient endpoint for services to
achieve optimal patient outcomes in specific patient groups or subgroups.
Vulnerable Group for Transitional Care
It is generally agreed that vulnerable groups such as the elderly,
the technologically dependent, the disabled, and some high risk infants and
children should receive transitional services.
Decisions regarding which
patients should receive these services are currently based on the patient’s
functional ability, available caregivers at home, ethnicity, age, previous
hospitalization, and technology dependency.
Types and Level of Transitional Care
Currently, there is wide variation in the type and level of
transitional care provider, and there is disagreement about who should provide
the care. Whether APNs are needed for transitional services to all patient
groups has not yet been tested.
Home care provided by professional nurses (RNs)
has been reported to decrease the negative psychosocial impact on parents
caring for medically fragile children at home. Improved patient outcomes using
home care provided by RNs also has been reported with ventilator dependent
children, with oncology patients, and with elders.
Effectiveness of Transitional Care
Data are also needed on the cost effectiveness of transitional care
compared to alternative approaches to care. Although the direct costs for
transitional care have been calculated in some studies, costs such as
prevention of rehospitalization, acute care visits, creased employment, and
burden on family caregivers are less well documented. These data are important
in examining the overall cost benefit or costeffectiveness of transitional
services.
Transitional care services are provided through public agencies;
private, not for profit agencies; freestanding and privately operated
proprietary agencies; freestanding and operated for profit, hospital-based
agencies; and dedicated units or departments operated by a hospital.
Transitional
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 known and accepted by the general public and health care providers.
Unfortunately, over the past 10 to 15 years, budget reductions for community
nursing services have virtually eliminated home follow-up services to many
patient groups.
Current challenges for community nursing services include
updating the specialty knowledge and skills of agency nurses with a generalist
preparation, maintaining continuity of patient care from the hospital to the
home, providing sufficient services to maintain continuity of patient care from
the hospital to the home, and providing sufficient services to maintain good
patient outcomes as insurers reimburse for fewer services.
the 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 hired discharge planners to facilitate
earlier discharge. 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 for discharging patients
early and for preventing costly re-hospitalizations. They have used case
managers and nurses with specialty knowledge and skills to review patients’
discharge and home care needs. Because realizing a profit is essential in the
for profit HMOs, their approach has been one of minimal hospital length of stay
and post discharge services.
Home follow-up services vary in number of visits
provided, type of nurse provider (nurse generalist or specialist), and length
of follow-up. More than the routine allowable for home visits may be
reimbursable for a patient, but this must be negotiated between provider and
insurer.
Future of Nursing Research and Transitional Care
Research is needed to determine: the nature, intensity, and length
of transitional services required to optimize patient and family outcomes; the
profile of patients who would benefit most from these services; the type and
level of providers needed to deliver these services; and the costs of such
services.
Continued study of existing and emerging model of transitional care
is also necessary to determine which of these models achieves the highest
quality and most cost-effective outcomes.
Study findings suggest that, for
selected patient groups or subgroups, discharge planning and home care
protocols designed to meet their unique needs are more effective than the
general protocols designed for all patients that is currently used by many
hospitals and home care agencies.
Targeted protocols should be derived from
empirical data regarding the unique needs of specific patient groups and their
caregivers after hospital discharge.
Transitional care protocols should be
based on an empirical understanding of the nature of the patients’ and
caregivers’ needs (eg, lack of knowledge, complexity of therapeutic regimen),
strengths (eg, supportive family) or barriers (eg, language) to meeting needs,
timing of needs (eg, 24 hours after discharge), most cost-effective strategy to
meet needs (eg, telephone contact vs. home visit), and length of follow up
needed.
Unfortunately, for many patient groups, this research base is limited.
For these patient groups, research efforts should be targeted first at
identifying patients’ and caregivers’ needs and subsequently at the design and
testing of interventions to meet their 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
providing continuity of care for patients and their caregivers. Study findings
also would advance our understanding about effective ways to engage a
multidisciplinary team of providers in transitional services.
Finally, the
knowledge generated from this research would determine the processes of care
that available data suggest are important to positive patient outcomes:
assessing, communicating, clinical decision making, teaching, collaborating,
referring, monitoring, and evaluating.