استعرض مصدر الرعاية الإنتقالية



Transitional care or care transition

==JCI==
http://www.jointcommission.org/toc.aspx

==good==
http://www.caretransitions.org/definitions.asp

==WP==
[[File:Here-to-there-arrows.jpg|thumbnail|transitional care help not getting lost while moving from here to there]]
'''Transitional care''' refers to the coordination and continuity of [[health care]] during a movement from one healthcare setting to either another or to home, called '''care transition''', between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. Older adults who suffer from a variety of health conditions often need [[health care]] services in different settings to meet their many needs. For young people the focus is on moving successfully from child to adult health services. 

[[File:Elderly care independancy.jpg|thumbnail|Elderly care must help keeping maximum dependency.]]
A recent position statement from the [[American Geriatrics Society]] defines transitional care as follows:<ref>[http://www.americangeriatrics.org/products/positionpapers/complex_care.shtml The American Geriatrics Society - Position Statements - Index<!-- Bot generated title -->]</ref> For the purpose of this position statement, transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Representative locations include (but are not limited to) [[hospital]]s, sub-acute and post-acute [[nursing home]]s, the patient’s home, primary and specialty care offices, and [[long-term care]] facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition. Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs.

==Defining and understanding transitional care==
[[File:Integrated CC-300x166.jpg|thumbnail|Transitional care aims at providing an integrated care]]
During transitions, patients with complex medical needs, primarily '''older patients''', are at risk for poorer outcomes due to medication errors and other errors of communication among the involved healthcare providers and between providers and patients/family caregivers. Most research in the area of transitional care has studied the transition from hospitalization to the next provider setting – often a sub-acute nursing facility, a rehabilitation facility, or home either with or without professional homecare services. Adverse patient outcomes include continuation or recurrence of symptoms, temporary or permanent disability and death. Healthcare utilization outcomes for patients experiencing poor transitional care include returning to the emergency room or being readmitted to the hospital. As healthcare expenditures rise at an unsustainable rate there is increasing focus by patients, providers and policymakers on restraining unnecessary resource utilization such as that incurred by preventable re-hospitalizations.

Transitional care or transition care also refers to the transition of '''young people with chronic conditions''' to adult based services. Transition care is a [[Youth Health]] service. As children mature into young adults, they outgrow the expertise of children’s services (paediatrics) and need to find an adult health service that suits them. A program in Australia [http://www.health.nsw.gov.au/gmct/transition/what.html GMCT Transition Care] is an initiative aimed at improving continuity of care for young people with chronic health as they move from children's (paediatric) to adult health services.

{{anchor|continuity}}

==Continuity of health care==
[[File:LTTCH Beechwood Entrance.jpg|thumbnail|Lake Taylor Transitional Care Hospital]]
Continuity of health care (also called ''[[Continuum (theory)|continuum]] of care''<ref name=Haggerty2003>{{cite doi|10.1136/bmj.327.7425.1219}}</ref>) is to what degree the care is coherent and linked, in turn depending on the quality of information flow, interpersonal skills, and coordination of care.<ref name=chsrf2002>[http://www.chsrf.ca/Migrated/PDF/ResearchReports/CommissionedResearch/cr_contcare_e.pdf Defusing the Confusion: Concepts and Measures of Continuity of Healthcare.] Robert Reid, Jeannie Haggerty, Rachael McKendry. Canadian Health Services Research Foundation. 01/03/2002</ref> Continuity of health care means different things to different types of caregivers, and can be of several types:
*[[Information continuity|Continuity of information]]. It includes that information on prior events is used to give care that is appropriate to the patient's current circumstance.<ref name=chsrf2002/>
*Continuity of personal relationships, recognizing that an ongoing relationship between patients and providers is the undergirding that connects care over time and bridges discontinuous events.<ref name=chsrf2002/>
*Continuity of clinical management.<ref name=chsrf2002/>
To avoid misinterpretation, the type of continuity should be agreed to before any related discussions or planning begin.<ref name=chsrf2002/> ''Seamless care'' refers to an optimal situation where there is continuity in the healthcare even in the presence of many transitions.<ref name=Haggerty2003/>

Analysis of [[medical error]]s usually reveals the presence of many gaps in health continuity, yet only rarely do gaps produce accidents.<ref name=cook2000>{{cite doi|10.1136/bmj.320.7237.791}}</ref> [[Patient safety]] is increased by understanding and reinforcing [[health care provider]]s' normal ability to bridge gaps.<ref name=cook2000/>

==Measuring quality of transitional care==

===Care Transitions Measure===
The only currently nationally endorsed measure of transitional care quality is the Care Transitions Measure (CTM), which is a 15-item survey for administration to patients after discharge from the hospital.<ref>[http://www.caretransitions.org/measures.asp Care Transitions Project, Health Care Policy and Research, Measures<!-- Bot generated title -->]</ref> The measure also exists as a 3-item survey. Patient responses to the survey predicts return to the emergency department and/or hospital. Dr. Eric Coleman and his team at the [[University of Colorado at Denver and Health Sciences Center]] developed the CTM, as well as an intervention designed to improve patient outcomes during transitions.

==Improving quality of transitional care==
After leaving a particular care setting, older patients may not understand how to manage their health care conditions or whom to call if they have a question or if their condition gets worse. Poorly managed transitions can lead to physical and emotional stress for both patients and their caregivers. During a transition, the patients' preferences or personal goals in one setting may not be passed on to the next setting. This may result in important elements of the care plan "falling through the cracks".<ref>({{cite journal
  | last = Coleman
  | first = Eric
  | authorlink = Eric A. Coleman
  | title = Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care for Persons with Continuous Complex Care Needs
  | journal = Journal of the American Geriatrics Society
  | volume = 51
  | issue = 4
  | pages = 549–555
  | date = April 2003
  | doi = 10.1046/j.1532-5415.2003.51185.x
  | pmid = 12657078  }}
)</ref>

Ideally, every patient's [[primary physician]] would be responsible for the patient through every health care process at all times, but this has been regarded as practically impossible, and, in reality, more effort must rather be put into making transitions more effective.<ref>[http://www.medscape.com/viewarticle/740856?src=mp&spon=25 Continuity of Care Starts With You] By Gregory J. Warth at Medscape. 04/21/2011</ref>

===Care Transitions Intervention===
The Care Transitions Intervention (CTI)<ref>[http://www.cfmc.org/providers/providers_pcc.htm Patient-Centered Care<!-- Bot generated title -->]</ref> is a coaching intervention to assist patients in resuming self-care following a change in health status. It uses coaching techniques to ensure that patients are comfortable in managing their own medications and their own health information, understand the signs and symptoms that should lead them to contact a healthcare provider, and have assertion skills to ask important questions of providers. Although the coaching intervention occurs for the first 30 days following the transition, this approach has been shown to significantly reduce hospital readmission as far out as 6 months.<ref>Please visit www.caretransitions.org for additional information.</ref>

In 2002, the [[University of Colorado Denver]] implemented a program called Care Transitions Intervention®. As part of the program, a Transitions Coach works directly with patients and family members for 30 days after discharge to help them understand and manage their complex postdischarge needs, ensuring continuity of care across settings. Participants in the program have a 20 to 40 percent lower hospital readmission rate at 30, 90, and 180 days postdischarge.<ref>{{cite web |publisher=Agency for Healthcare Research and Quality |url=https://innovations.ahrq.gov/profiles/transition-coaches-reduce-readmissions-medicare-patients-complex-postdischarge-needs |title=Transition Coaches Reduce Readmissions for Medicare Patients With Complex Postdischarge Needs |date=2013-04-10 |accessdate=2013-05-10}}</ref>

==Turfing==
''Turfing'' is where a healthcare provider transfers a patient they could have taken care of to another provider in order to reduce their own patient load.<ref>{{cite doi|10.1046/j.1525-1497.1999.00325.x}}</ref>  According to one study in the US, 9 percent of physicians admitted that they had transferred a patient in such manner.<ref>[http://www.medscape.com/viewarticle/765719?src=mp&spon=25 Doctors Admit to Unprofessional Behavior in Study at 3 Chicago Hospitals]. By Jordan Rau. From Kaiser Health News, June 2012</ref>

==See also==
*[[System of concepts to support continuity of care]]
*[[Lake Taylor Transitional Care Hospital]]

==References==
<references />


[[تصنيف:طب مسنين]]
[[تصنيف:الرعاية الصحية للمسنين]]