Learning Objectives
By the end of this section, you will be able to:
- Discuss the process of discharge planning for patients requiring continued services
- Describe the role of nurse case managers in supporting patients through the care continuum
- Explain how collaborative care functions and supports positive patient outcomes
A change from one patient setting to another outside of a hospital setting is called transitional care. It could be a change from the emergency department to another medical-surgical department, or a transition from a hospital to a rehabilitation center and then back home. Transitions and continuity of care play a central role in health care’s ever-evolving landscape and represent key moments on an individual patient journey. They focus on the process of helping patients move between health-care settings to ensure seamless health-care experiences that focus on patient needs and positive outcomes. Transitioning between care settings and changing treatment plans are critical junctures that must be handled carefully to avoid errors or disruption. Through an examination of strategies, challenges, and key roles in ensuring continuity, this section explores how health-care systems can integrate all their various components effectively to offer patients optimal care outcomes.
Discharge Planning for Community or Home Care Settings
In home and community-based care settings, discharge planning is an organized process designed to facilitate a safe transition for patients from health-care facilities, like hospitals or rehabilitation centers, back into their own home or a care setting of choice. This process aims to ensure patients receive all the support, resources, and follow-up care necessary for ongoing recovery and self-management of health outside the hospital setting. Effective discharge planning is essential in avoiding readmissions, improving patient outcomes, and supporting overall well-being in the home or community environment. Key components of discharge planning in an inpatient or home care setting include collaborative decision-making, the creation of a care plan, patient education, medication reconciliation, home safety assessment, and coordination of assessment, care, services, and follow-ups.
Discharge planning begins with a detailed evaluation of a patient’s physical, psychological, and social needs. Health-care providers, such as nurses, case managers, and social workers, collaborate in this assessment to ascertain the patient’s level of independence, support network, and required services. Together with the patient, the nurse will review the patient’s health status, treatment plan, and medication management needs, as well as any lifestyle modifications required, before discharging the patient from health-care services.
Based on the assessment, an individualized care plan is developed and tailored specifically for each patient. The care plan may include details regarding medications, wound-care treatments, and equipment requirements as well as diet restrictions, exercise routines, and follow-up appointments. Discharge planners collaborate with health-care providers, community resources, and home-care agencies to coordinate services and support needed upon discharge from hospital care, including home health nursing services, physical therapy services, occupational therapy treatments, medical equipment delivery, and social services for their patients.
Patient education is an important component of discharge planning. Both patients and caregivers need to receive education about their conditions, treatment plans, medications, signs, and complications, as well as self-care strategies, to actively manage their own health at home. Discharge planners need to ensure their patients understand their medication regimen, including dosages, frequency, and potential side effects. They may arrange prescriptions from community pharmacies as well as home delivery services.
Home environments will be assessed to ensure they meet patient safety needs and accommodate mobility difficulties or medical equipment, with modifications recommended as appropriate for safety and functionality. Lowered countertops in the kitchen, wider doors, and easier-to-manipulate door handles may be some of the modifications needed to ease the transition to a home setting. Appointments will be scheduled with the patient’s care provider after initial assessments to provide any needed follow-ups and updates as appropriate. Follow-up appointments will then take place to review how treatment has gone so far and offer recommendations where needed. Discharge planners facilitate these follow-up appointments between patients, primary care physicians, specialists, and health-care providers to monitor patient progress and adapt the care plan as necessary. Effective communication among all members of the care team is of utmost importance, and discharge planners ensure medical records, care plans, and instructions are communicated accurately to home-care providers, caregivers, and the patient.
The Nurse’s Role in Discharge Planning
Nurses play a crucial role in supporting patients through their transition from inpatient to outpatient services. This transition is a critical juncture in a patient’s health-care journey, and nurses contribute significantly to ensuring a smooth, safe, and successful shift from the hospital to a less-intensive care setting. Nurses provide essential education to patients and their caregivers about the patient’s condition, medications, treatment plan, and self-care strategies. This education empowers patients to actively participate in managing their health and follow recommended practices after discharge.
Nurse Case Management
The role of a nurse case manager in community or home care settings is multifaceted and essential for ensuring the provision of high-quality, patient-centered care to individuals who require ongoing medical attention, support, and coordination of services in their homes or within the community. Nurse case managers play a pivotal role in facilitating effective communication, coordinating care services, and advocating for the well-being of their patients. A nurse case manager functions in acute care settings as well as in managed care organizations, rehabilitation centers, and long-term settings.
Collaborative Care
Also referred to as interdisciplinary or interprofessional care, collaborative care is an approach to health care that stresses collaboration among multiple health-care providers from different fields to deliver comprehensive and holistic treatment to patients. This approach acknowledges that health conditions often involve complex interactions spanning various domains and require specialists from diverse fields to properly meet patients’ physical, psychological, emotional, and social needs. Collaborative care aims to optimize patient outcomes, elevate quality care delivery, and create patient-centered experiences. It involves teamwork, effective communication, and shared decision-making as part of its approach toward health challenges. Key characteristics and components of collaborative care include interdisciplinary teams, effective team communication, coordination of patient care, and patient-centered care.
Depending on the patient’s needs, a collaborative care team may include physicians, nurses, pharmacists, social workers, PTs, occupational therapists, and psychologists, all of whom collaborate closely for patient care. Each team member brings their unique expertise to address various aspects of patient health. All team members work toward common goals related to improving well-being, safety, and recovery for the patient. Goal setting should begin with knowledge of the patient, including their preferences and needs. Involvement from every member in this endeavor is of vital importance for meeting goals effectively.
Collaborative care ensures that care interventions and services are coordinated to minimize duplication, address gaps in care delivery, and maximize resource use, thus improving patient experiences while preventing fragmentation of care services. In collaborative health care, patients’ preferences, values, and goals are taken into consideration when making care decisions. This approach empowers patients to actively take part in their treatment plans. Health-care professionals collaborate closely with patients and their family members, helping them make well-informed decisions regarding treatment options, interventions, and care plans. Patients’ input is considered when making these choices.
Referring patients to support groups or peer-led programs can provide emotional support, shared experiences, and a sense of community for individuals facing similar health challenges.
Referrals to dietitians or nutritionists support patients with dietary restrictions or those needing guidance for managing specific conditions through proper nutrition. Referrals to pharmacists or medication management programs help patients better understand and adhere to their medications and regimens, managing side effects as necessary and adhering to prescribed regimens.