Transitional Care In Health Care System

Health Care System and Transitional Care

What is Transitional Care,Features of Transitional Care,Issues In transitional Care,Vulnerable Group for Transitional Care,Types and Level of Transitional Care,Effectiveness of Transitional Care,Community Health Nursing and Transitional Care,Future of Nursing Research and Transitional Care.

What is Transitional Care

    Transitional care refers to care and services required in the safe and timely transfer of patients from one level of care to another or from one type of health care setting to another (Brooten, 1993). Transitional environments include the hospital, home, nursing home, rehabilitation center, and hospice. Some authors differentiate subacute care from transitional care; others use the terms interchangeably. 

    Those who make the distinction view subacute care as a unit or component of inpatient care in an acute care facility, skilled nursing facility, or freestanding medical or rehabilitation center. 

    Transitional care ideally ends with normal functioning and recovery, functional independence, or stabilization of the patient's condition (Brooten). In the case of many friar children or adults, transitional services end in long term care.

Features of Transitional Care

    Key features of transitional care include comprehensive discharge planning from one site of care to another, coordination of post discharge services, provision of in-home services on a short-term basis, and continued health care follow up. 

    The most important components of transitional care services are continuity of care across sites of care, communication of the plan of care among the differing providers, and matching patient needs and knowledge with skills of the care providers.

    Transitional care services have increased significantly over the past 10 to 15 years in response to changes in health care delivery, especially earlier hospital discharge of patients.

Issues In transitional Care

    Research issues in transitional care include determining the nature and length of the service needed, risk profiles of patients who need the service, type and level of providers needed, and cost effectiveness of the service compared to alternative services. 

    The length of transitional services should vary with the specific needs of the patients or group of patients rather than being dictated by the reimbursement plan. However, data are not available demonstrating the most effective and cost efficient endpoint for services to achieve optimal patient outcomes in specific patient groups or subgroups.

Vulnerable Group for Transitional Care

    It is generally agreed that vulnerable groups such as the elderly, the technologically dependent, the disabled, and some high risk infants and children should receive transitional services. 

    Decisions regarding which patients should receive these services are currently based on the patient's functional ability, available caregivers at home, ethnicity, age, previous hospitalization, and technology dependency.

Types and Level of Transitional Care

    Currently, there is wide variation in the type and level of transitional care provider, and there is disagreement about who should provide the care. Whether APNs are needed for transitional services to all patient groups has not yet been tested. 

    Home care provided by professional nurses (RNs) has been reported to decrease the negative psychosocial impact on parents caring for medically fragile children at home. Improved patient outcomes using home care provided by RNs also has been reported with ventilator dependent children, with oncology patients, and with elders.

Effectiveness of Transitional Care

    Data are also needed on the cost effectiveness of transitional care compared to alternative approaches to care. Although the direct costs for transitional care have been calculated in some studies, costs such as prevention of rehospitalization, acute care visits, creased employment, and burden on family caregivers are less well documented. These data are important in examining the overall cost benefit or costeffectiveness of transitional services.

    Transitional care services are provided through public agencies; private, not for profit agencies; freestanding and privately operated proprietary agencies; freestanding and operated for profit, hospital-based agencies; and dedicated units or departments operated by a hospital. 

    Transitional services are provided by community nursing services, hospital home care services, health maintenance organization (HMO) follow up services, and subacute care units established within hospitals or skilled nursing facilities. or as freestanding subacute care hospitals.

Community Health Nursing and Transitional Care

    Community or public health nurses have historically provided home follow-up to high risk patients with complex health needs. Their services are well known and accepted by the general public and health care providers. Unfortunately, over the past 10 to 15 years, budget reductions for community nursing services have virtually eliminated home follow-up services to many patient groups. 

    Current challenges for community nursing services include updating the specialty knowledge and skills of agency nurses with a generalist preparation, maintaining continuity of patient care from the hospital to the home, providing sufficient services to maintain continuity of patient care from the hospital to the home, and providing sufficient services to maintain good patient outcomes as insurers reimburse for fewer services.

     As reimbursed length of stay for even high risk patients decrease, the hospitals' need for improved discharge planning and post discharge home care services for these groups increases. 

    Documented discharge planning is mandatory for hospitals, and many have hired discharge planners to facilitate earlier discharge. Some hospitals contract with community nursing services or independent home care agencies to provide home care services for their high-risk patients. An increasing number of hospitals are establishing their own home care services.

    HMOs have a clear financial incentive for discharging patients early and for preventing costly re-hospitalizations. They have used case managers and nurses with specialty knowledge and skills to review patients' discharge and home care needs. Because realizing a profit is essential in the for profit HMOs, their approach has been one of minimal hospital length of stay and post discharge services. 

    Home follow-up services vary in number of visits provided, type of nurse provider (nurse generalist or specialist), and length of follow-up. More than the routine allowable for home visits may be reimbursable for a patient, but this must be negotiated between provider and insurer.

Future of Nursing Research and Transitional Care

    Research is needed to determine: the nature, intensity, and length of transitional services required to optimize patient and family outcomes; the profile of patients who would benefit most from these services; the type and level of providers needed to deliver these services; and the costs of such services. 

    Continued study of existing and emerging model of transitional care is also necessary to determine which of these models achieves the highest quality and most cost-effective outcomes. 

    Study findings suggest that, for selected patient groups or subgroups, discharge planning and home care protocols designed to meet their unique needs are more effective than the general protocols designed for all patients that is currently used by many hospitals and home care agencies. 

    Targeted protocols should be derived from empirical data regarding the unique needs of specific patient groups and their caregivers after hospital discharge. 

    Transitional care protocols should be based on an empirical understanding of the nature of the patients' and caregivers' needs (eg, lack of knowledge, complexity of therapeutic regimen), strengths (eg, supportive family) or barriers (eg, language) to meeting needs, timing of needs (eg, 24 hours after discharge), most cost-effective strategy to meet needs (eg, telephone contact vs. home visit), and length of follow up needed. 

    Unfortunately, for many patient groups, this research base is limited. For these patient groups, research efforts should be targeted first at identifying patients' and caregivers' needs and subsequently at the design and testing of interventions to meet their unique needs.

    There is a need for studies that compare and contrast existing and emerging models of transitional care, focusing on differences in both processes and outcomes of care. 

    Knowledge generated from studies of these models would contribute to the ongoing discussion and debate about which providers are most effective and efficient in coordinating transitional care services and providing continuity of care for patients and their caregivers. Study findings also would advance our understanding about effective ways to engage a multidisciplinary team of providers in transitional services. 

    Finally, the knowledge generated from this research would determine the processes of care that available data suggest are important to positive patient outcomes: assessing, communicating, clinical decision making, teaching, collaborating, referring, monitoring, and evaluating.