Over the last three years, hospitals worldwide have faced a significant rise in patient visits, particularly in the inpatient and emergency departments, all thanks to the COVID-19 pandemic. This sudden upsurge in traffic has led to an overwhelming burden on the healthcare staff and facilities to the extent that nurses, doctors, and other healthcare providers are now seeking jobs in less stressful work environments outside of the hospital. 1
During the pandemic, referrals for home health services increased due to the rising prevalence of chronic illnesses such as CHF, COPD, and diabetes. 2
Patients are often discharged from hospitals to their homes without enough resources or knowledge to manage their medical conditions, which leads to a higher risk of being readmitted to the hospital. This situation arises due to the shortage of home healthcare providers and the lack of proper communication regarding follow-up appointments with primary care providers. In an environment where healthcare professionals are not paid adequately, and medical institutions are often understaffed, patients can face considerable delays in receiving care from a home health nurse or therapist. Sometimes, patients must wait for up to a week before they can begin their recovery at home. These delays can have a negative impact on patient outcomes and recovery time, often resulting in avoidable rehospitalizations. 3
With the recognition of the needs of chronically ill patients, care transition clinicians have emerged to reduce the burden on hospital staff, patients, and primary care providers. 4
Care Transition is a process that takes place after a patient is discharged from the hospital or emergency room. Within 48 hours of discharge, a care transitions nurse will contact the patient to:
· Review and reconcile their medications.
· Provide education on chronic disease management or post-operative care.
· Ensure that the patient has scheduled follow-up appointments with their primary care provider and/or specialist.
· Assist patients who require referrals for primary care, specialty care, or behavioral health.
This service aims to ensure that patients are provided with the necessary support and information to manage their health condition effectively after their hospitalization. 5
Often, the role of care transition extends beyond just hospital discharge. Experienced clinicians can identify patients who may need more time to understand their illnesses. They can arrange regular phone or virtual meetings to help these patients transition from hospital to home and manage their health with the help of a family member, friend, or primary care provider.
Implementing care transitions has been shown to effectively decrease rehospitalization rates, thereby reducing the penalty burden on hospitals. This approach guarantees that patients can avoid hospitalization during the critical 30-day period, where penalties can significantly impact the hospital or healthcare institution. 6
To summarize, Care Transitions have a vital role to play in our healthcare system. They assist patients by offering the required support when they are at home, educating them about their illnesses, reconciling their medications, and linking them with healthcare providers. This leads to a decrease in the burden on hospitals, staffing, and financial resources, thereby avoiding the need for unnecessary rehospitalizations.
Assessed and Endorsed by the MedReport Medical Review Board