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Mar 23, 2017

How Post-Acute Care Professionals Can Excel in Transitional Care


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medical recordsPoor transitions can affect every aspect of patient care and lead to medication errors, falls, infections and other problems that could jeopardize the future of your facility. If transition problems are severe and ongoing, hospitals may soon decide to recommend other facilities to patients and their families. But there are a few things you can do to optimize transitional care, reduce risk and improve post-acute care outcomes. Here are four things you should add to your transitional care process immediately.

1. Request Detailed Facility Transfer Reports

Facility transfer reports provide important details you need to treat new patients. But too often, the reports aren’t comprehensive. Diagnoses, vital signs, current medications and allergies are important information, but if you don’t know where a patient’s hearing aid is, or even if he or she normally wears a hearing aid, communicating with a newly arrived patient will be difficult.

If you’re concerned about the quality of transfer reports you receive, meet with hospital case managers and jointly create forms that provide the information you need to ensure you’re providing the best care. The small details the hospital might not consider important may be of critical importance to you and your team.

For example, when you know that a patient can’t swallow pills, you can make sure you stock another form of the medication. Or you may discover the hospital PT had better luck using one type of rehab equipment over another.

2. Make Briefings a Priority

Make sure all staff members who will interact with the patient are briefed on the information contained in the transfer report before or immediately after a new patient arrives. If possible, speak to a nurse or another provider before the transition and ask if there’s anything you should know that might not appear on the transfer report. Share contact information for case managers, physicians or others with staff members who will be following the patient’s progress.

3. Share the Care Plan

Patients are more likely to be compliant and participate in their care when they understand post-acute treatment goals. Since the post-acute care plan may be different than the acute care plan, discussing the plan as soon as the patient is admitted to your facility is crucial. If patients don’t understand why they are at your facility, or aren’t receiving a particular treatment or medication, they may quickly become dissatisfied with their care. It’s much easier to spend a few minutes discussing the plan than hours working to resolve complaints from patients and their family. It may be helpful to use the “teach back” method when you explain the care plan. The method involves sharing key aspects of the plan and asking the patient to then explain them to you. If possible, make sure family members are present to prevent misunderstandings about care plan goals.

4. Upgrade Your EHR System

Thanks to electronic health records (EHR), sharing medical records, test results and other information with other providers is quick and easy. Unfortunately, poorly designed or inefficient systems can make it difficult to access the information you need quickly.

If your post-acute care facility regularly receives patients from the same group of referring hospitals, using the same EHR system that the hospitals use can make it easier to get the information you need. It will also enable the referring hospital to track patient progress easily.

A smooth transition not only helps your staff provide the level of care patients require, but also helps patients feel comfortable during a potentially confusing and emotional experience. Taking steps to improve care transitions offer important benefits that can help your facility remain competitive. 

Looking for more ways to improve outcomes? Check out our free guide, Better Rehab Solutions for Better Outcomes, to learn more about our innovative products.


Topics: Post-Acute Care



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