NUR 460 Week 3 Transitions of Care PDF

**[Week 3 -- Transitions of Care ]** **What are transitions of care?** - A set of actions designed to ensure the coordination and continuity of health care as pts transfer between different locations or different levels of care within the same location - From home to hospital or r...

**[Week 3 -- Transitions of Care ]** **What are transitions of care?** - A set of actions designed to ensure the coordination and continuity of health care as pts transfer between different locations or different levels of care within the same location - From home to hospital or residential care setting - From hospital to home - Between hospital wards - From hospital to hospital or residential care setting - Consultations in out-patient facilities - Transitions of care are high-risk scenarios for pt safety: - Inc in morbidity - Inc in mortality - Inc in adverse events - Delays in receiving appropriate tx and community support - Additional primary care emergency department visits - Additional or duplicated tests or test loss to follow up - Preventable readmissions to hospital - Emotional and physical pain and suffering for patients, carers and families - Patient and provider dissatisfaction with care coordination - Transfer: allows safe efficient transfer of responsibility from one care provider to another or one facility to another ensuring all required information needed to properly care for the client is available to the receiver **Intersection of risk factors** - The intersection of risk factors associated with patient transitions - Consider perils at each step and anticipate needs related to safe transfer +-----------------------+-----------------------+-----------------------+ | **Patient Factors** | **Personnel Factors** | **System Factors** | +=======================+=======================+=======================+ | - Vulnerable: | - Receiving | - Mode of transfer | | elderly, peds, | personnel: who? | | | etc. | Ability to manage | - Receiving | | | the pt | organization is | | - SDOH | | able to manage | | | - Qualifications | client | | - Support systems | | | | | - Adequate staffing | - The right client | | - Capacity: to make | | in the right | | decisions | - Part of | place at the | | | collaboration | right time? | | - Burden of illness | related to | | | | transfer | | | - Mobility: ability | | | | to get to appts | | | | and carry out tx | | | +-----------------------+-----------------------+-----------------------+ **Providing safer care transitions** - Beneficial interventions: - Standardizing documentation and agreeing on which information should be included in referral and discharge documents - Discharge planning with agreed criteria and protocols - Improving the quality and timeliness of discharge documentation - Improving the effectiveness and timeliness of clinical handovers between clinicians - Implementing effective medication reconciliation practices - Conducting timely and appropriate pt follow ups, including telephone calls and home visits - Educating and supporting patients, families and carers - Assigning care coordinators (core nurses) or case managers to people with complex needs - Establishing primary care hotline to hospital ED - Increasing the involvement of primary care physicians and nurse practitioner **Common causes of readmission** - Adverse drug events - Therapeutic errors - Infections - Diagnostic errors - Procedural complaints **Medication reconciliation** - Medications including reasons for starting meds, altering meds, stopping meds - Dose, route, proposed duration of medication tx - \>40% of medication errors result from inadequate reconciliation in handoffs during hospital admission, transfer and discharge **Follow up plan** - What's next? - When to see PCP and/or other specialists - Outpatient investigations to be completed - Specific instructions **Need for transition support** - Family has to coordinate care in a new and fragmented system - Various system models in adult care (in comparison to pediatric care) - Inc demand for treating children with complex care that adult care practitioner hasn't been trained to do - Inc anxiety for care providers and pts **Core principles of transition planning** - Start early - Individualized planning - Provide support before transition - Ensure ongoing support **Start transition planning early** - Regularly assess transition readiness of pt and caregivers - Ensure adequate dedicated time to the transition process - Understand youth's potential and goals for activity, education, recreation, and vocation - Beginning at 12-14 is ideal -- to be knowledgeable of their own care - Start transition slowly - Good time to make connection with family care provider around 14 y/o - Still maintain pediatric care but also have family HCP - 17 years old is good for specialists **Create an individualized transition plan** - Identify a transition 'champion' - Identify key multidisciplinary clinicians as well as primary care - Solicit care needs from youth and parents/caregivers - Address gaps in youth preparedness, autonomy and confidence - Develop a transition plan - Comprehensive medical summary and anticipatory guidance - Complete a transition readiness checklist - Review and update the transition plan regularly - Provide developmentally appropriate care and support **Provide support before transition** - Provide education and peer support for youth and caregivers - Support youth with a stepwise approach to increasing independence in care management - Create a comprehensive health transfer summary based on youth and caregiver priorities - Include strengths, hopes, considerations re QoL - Provide summary to youth and clinicians - My health 3 sentence summary - My age, diagnosis and brief medical history - My tx plan is - My question/concern to talk about during this visit **Provide support before transition: connection to primary care provider** - Have a nurse find you a doctor or NP through health care connect - However, joining health care connect does not guarantee that: - A family HCP will be found for. You -- those who need urgent care will be placed with a family HCP first - One family HCP can take your whole family **Provide support before transition: funding transition and future planning** - Government funding - Developmental Services Ontario DSO - Ontario Disability Support Program -- ODSP - Private funding options - Registered disability savings plan -- - Henson trust **Provide support before transition: Overlap in care** - Initiate referrals prior to the 18^th^ birthday -- starting early is KEY to reduce shock for pt and families - Build capacity in adult care providers for childhood onset conditions - Early introduction to the adult system - Adult care is focused on independent and assuming care of personal conditions - Ensure connection to care - Supports continuity and collaborative practice **Ensure Ongoing support AFTER transition** - Ensure youth attend appts - Assess youth's attachment to adult services - Continue to involve caregivers as per youth's wishes, with gradual weaning over time - Measure outcomes routinely **The take home on transition to adult care** - Start early - Overlap in care - Individualized transition planning - Capacity building and self-directed care - Build connections in the adult system - Ensure primary care provider connection - Medical summary and anticipatory future needs - i.e. having children, etc. - considering what they need when growing up or down the line **Summary/Key Points: Recommendations to Improve Transition to Adult Care for Youth with Complex Health Needs** - **Youth with Complex Health Needs**: Require specialized physical, developmental, and/or mental health services, transitioning from pediatric to adult care typically between ages 16-19 in Canada. - **Challenges in Transition**: - Fragmentation of pediatric and adult care services disrupts continuity, risking poor health outcomes. - Youth face multiple challenges, including physical, psychosocial, and developmental changes. - Conditions such as diabetes, cystic fibrosis, congenital heart disease, and organ transplants see worsened outcomes post-transition. - Gaps in care during transition lead to patient disengagement, poor treatment adherence, and increased hospitalization. - **Core Transition Planning Principles**: - **Start Early**: Assess readiness regularly; involve patients and caregivers in discussions. - **Create Individual Plans**: Appoint a transition \"champion\"; involve multidisciplinary teams. - **Pre-transition Support**: Provide education and peer support; prepare transfer summaries. - **Post-transition Support**: Ensure continued care, measure outcomes, and maintain family involvement if necessary. - **Barriers**: - Limited evidence for effective transition interventions, especially for youth with medical complexity or technology dependence. - Lack of integration between pediatric and adult services, especially for primary care providers, who often feel unprepared for the complexity of care needed. - Disparities for youth from rural or marginalized communities. - **Recommendations**: - **Continuous and Coordinated Care**: Ensure care is integrated, involving both pediatric and adult health teams. - **Flexible Age Cut-offs**: Tailor transition timing to individual development and capacity rather than chronological age. - **Collaboration**: Pediatric and adult care providers should develop joint strategies for smoother transitions. - **Quality Indicators**: Redefine indicators to better track improvements in care and outcomes for youth with complex needs. - **Training**: Build specialized training and education for providers across different settings to handle transitional care. - **Flexible Funding**: Advocate for adaptable funding models that support shared care during the transition phase. This summary highlights the key points and recommendations for improving the transition process for youth with complex health care needs.