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ADVANCE Perspective: Nurses

Maximizing Transitional Care

Published April 17, 2013 11:02 AM by Guest Blogger
By Diane M. Goodman, APRN, BC, MSN-C, CCRN, CNRN

Your patient is about to leave the inpatient facility for home, where they will need to manage approximately 3.4 chronic diseases (if they are a typical senior ≥ the age of 65, according to the CDC, U.S. Health Statistics). How do we assure patient readiness in our rush to find a wheelchair, a transporter and the lengthy list of medications they have been prescribed? This is easy. We don't. Planning for patient discharge must be accomplished from the point of entry, and reinforced with every "teachable" moment providing care.

Healthcare transitions have become a hot topic, and one we will be hearing much more about in the future. We cannot expect patients with chronic disease to grasp "disease management" on their way out the door, nor would we realistically expect them to remember medication side effects and pain plans that hadn't been explained throughout their stay.

As mentioned in previous blogs, I have a chronic neuromuscular disorder that intermittently demands my undivided attention. My husband understands the gravity of discussing financial issues when my neurons are saturated. I could swear he insisted I spend unlimited funds in Sephora over the weekend, simply because my brain had stopped processing information. This is similar to how our patients feel when they've seen the sixth specialist on a day crammed with diagnostic testing and no food.

Transitional care is preparing the patient for another "level" of caregiving, and if that means going home with minimal support, we need to prepare them early and often for potential consequences. We need to ask what they know about their condition. We must also identify gaps in their knowledge base. Additionally, patients should be provided with as many resources as possible to contact once they leave the hospital.

Providing patients with a follow-up physician appointment does not assure they will go, even if they comprehend the necessity. Frankly, when I am discharged from the hospital, the last person I want to see is another physician or phlebotomist. I much prefer a hot date with the couch, my favorite TV programs, and a few snacks that don't arrive lukewarm on a tray (pass the salt, anyone?). But the patient can and will pick up the phone if they feel uneasy regarding post-discharge care. In order to maximize transitional care, we need to spend time thinking like a patient, and walking in their shoes. As soon as we remove those shoes on admission, that is the ideal time to think "discharge."


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