Case Management and Transition of Care

In case management, when we talk about Transition of Care, we’re referring to what is done for patients who are moved from one location to another and/or new levels of treatment during their health care process.  This includes any move, whether it’s from the ER to an in-patient bed, ICU to “the floor”, or in-patient care to home.

So what exactly is done within the context of this Transition of Care?  Part of our responsibility during this critical time is to ensure that our patients don’t get lost in the shuffle or fall between the cracks.  We coordinate the continuity of care by building a bridge between all the involved parties…physicians from different departments and disciplines, nurses, pharmacists, home health care and others… making sure that everyone is on the same page each step of the way.

Of great importance is the involvement of family members who are either standing watch during hospital stays or who will be caregivers once the patient is released to go home to recover.  It’s our goal to help our patients and their families succeed at whichever step comes next in their medical regimen.   Part of our transition plan is to provide patients and families the knowledge they need to understand what is coming during this change and share an awareness of problems that may arise, as well as how to deal with them.

We place a great deal of emphasis on collaborating with all health care providers and parents so that our patients are set up to succeed at the next level of care.  It’s important to have all our ducks in a row before moving a patient to that next level, with resources in place in order to avoid a potential failure during the transition, taking a proactive approach, rather than reactive.

Because re-hospitalization is a real and common issue among those who are chronically ill, a well-coordinated transition of care plan can save patients and families enormous amounts of stress, both emotionally and physically, while at the same time save on the expense of being re-admitted to a health-care facility again.

Enough can’t be said about the emphasis that should be placed on transition of care for all who are a part of a patient’s recovery.  If you have a transition of care question or story you’d like to share, we’d love to hear from you.