Care Transitions In Nursing Essay
Care transitions is described as a process when patient’s care shifts from being provided in one setting to another, for instance moving from a hospital to a patient’s home.46 Patients with complex care needs often require care at different settings. During care transitions, these patients often experience difficulties in managing their care and face problems of care fragmentation. Managing care transitions is important since inadequate management contributes to $25 to $45 billion in wasteful spending mainly through avoidable complications and unnecessary health care utilization.46 The famous report by the Institute of Medicine, Crossing the Quality Chasm, highlighted this issue and reported that upon hospital discharge, patients receive little
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The Care Transitions Intervention developed by Eric Coleman utilized nurses and social workers to promote development of patient’s skills in four key self-care areas including managing medications, timely follow-up care, identifying and responding to ‘red-flags’ (onset of a fever or worsening of a condition), and having a patient-centered record owned by the patient to simplify information transfer. The program evaluation demonstrated a 30% reduction in 30-day hospital readmissions, 17% reduction in 180-day hospital readmission, and reduced average cost per patient by 17%. Another care transitions model that has been evaluated is the Naylor model developed by Mary Naylor and colleagues. The intervention targeted high-risk, high-cost elderly patients and was provided for a longer period. The program evaluation reduced readmissions by 36% and costs by 39% per patient during 12 months following hospitalization. This program not only provided interventions in the hospital setting but also extended it to the community setting by incorporating regular home visits. However, care transitions models developed so far have not primarily focused on identifying and resolving medication-related issues during care transitions. There is a lack of evidence regarding the effectiveness of medication management interventions during care transitions, especially among vulnerable, high-risk patients with chronic conditions and
The Care Transitions Intervention developed by Eric Coleman utilized nurses and social workers to promote development of patient’s skills in four key self-care areas including managing medications, timely follow-up care, identifying and responding to ‘red-flags’ (onset of a fever or worsening of a condition), and having a patient-centered record owned by the patient to simplify information transfer. The program evaluation demonstrated a 30% reduction in 30-day hospital readmissions, 17% reduction in 180-day hospital readmission, and reduced average cost per patient by 17%. Another care transitions model that has been evaluated is the Naylor model developed by Mary Naylor and colleagues. The intervention targeted high-risk, high-cost elderly patients and was provided for a longer period. The program evaluation reduced readmissions by 36% and costs by 39% per patient during 12 months following hospitalization. This program not only provided interventions in the hospital setting but also extended it to the community setting by incorporating regular home visits. However, care transitions models developed so far have not primarily focused on identifying and resolving medication-related issues during care transitions. There is a lack of evidence regarding the effectiveness of medication management interventions during care transitions, especially among vulnerable, high-risk patients with chronic conditions and