RT Book, Section
A1 Eng, Jessica A.
A1 Flint, Lynn A.
A2 Walter, Louise C.
A2 Chang, Anna
A2 Chen, Pei
A2 Harper, G. Michael
A2 Rivera, Josette
A2 Conant, Rebecca
A2 Lo, Daphne
A2 Yukawa, Michi
SR Print(0)
ID 1180015193
T1 Transitions and Continuity of Care
T2 Current Diagnosis & Treatment Geriatrics, 3e
YR 2021
FD 2021
PB McGraw-Hill Education
PP New York, NY
SN 9781260457087
LK accessmedicine.mhmedical.com/content.aspx?aid=1180015193
RD 2024/04/16
AB The  term  care  transition  refers  to  the  transfer  of  a  patient’s  care  from  one  setting  and/or  team  of  clinicians  to  another.  The  most-studied  care  transition  is  hospital  discharge,  which  is  often  more  complex  than  a  simple  return  home.  What  follows  is  an  example  of  a  typical  series  of  transitions  after  hospitalization:  An  older  adult  with  a  chronic  condition,  followed  as  an  outpatient  by  his  primary  care  physician  and  a  specialist,  is  hospitalized  for  exacerbation  of  the  chronic  condition,  where  a  hospital-based  generalist  and  specialist  physicians,  nurses,  and  therapists  care  for  the  patient.  The  hospitalization  is  this  patient’s  first  transition.  During  the  hospitalization,  the  patient  may  move  between  units  within  the  hospital  due  to  changing  care  needs,  a  second  transition.  When  the  patient  no  longer  requires  acute-level  care,  the  patient  may  receive  postacute  care  (PAC)  from  a  new  team,  such  as  rehabilitation  or  skilled  nursing  care,  in  a  facility  or  at  home,  a  third  transition.  When  the  patient  is  discharged  from  the  facility  or  home  health  team,  a  fourth  transition  occurs.  With  so  many  handoffs,  mishaps  are  inevitable.  Transitional  care  broadly  refers  to  time-limited  care  processes  aimed  at  avoiding  such  mishaps  and  ensuring  safe  and  minimally  disruptive  transfers  of  care  between  different  sites  and  clinicians.