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Population Health for Nurses

30.1 The Effects of Care Coordination and Care Transitions on Outcomes

Population Health for Nurses30.1 The Effects of Care Coordination and Care Transitions on Outcomes

Learning Outcomes

By the end of this section, you should be able to:

  • 30.1.1 Describe the terms transitional care and care coordination.
  • 30.1.2 Identify factors that contribute to poor transitions of care outcomes.
  • 30.1.3 Explain how transitional care improves health outcomes.

Transitional care refers to a comprehensive and coordinated set of actions designed to ensure the safe and smooth transfer of clients. It encompasses a range of services and interventions aimed at supporting individuals as they move from one health care provider or facility to another or from one stage of care to another, such as from hospital to home or from acute care to rehabilitation.

The primary goal of transitional care is to optimize continuity and quality of care during these transitions, ensuring that clients experience seamless and coordinated health care. Effective care transitions and care coordination are essential components of a well-functioning health care system. They contribute to improved client outcomes, enhanced client experiences, and reduced health care costs. By ensuring seamless information exchange, collaborative decision-making, and comprehensive care planning, care transitions, and care coordination can minimize care gaps prevent adverse events, and promote optimal health outcomes for individuals in the community.

Community health nurses play a crucial role in facilitating transitional care for clients by managing the transfer of information, responsibilities, and support services between health care providers, settings, and clients themselves. They serve as key coordinators of care, provide education and support to clients and families, and facilitate smooth and effective transitions between health care settings (Institute of Medicine, 2010). To achieve this, community health nurses rely on a set of essential skills and competencies, including care coordination, client education, interdisciplinary collaboration, and communication, among others (Iwamoto, 2023). Additionally, community health nurses are well-positioned to engage in follow-up care activities, such as medication management, home visits, and referrals to community-based resources. These interventions are critical components of transitional care that enhance client safety, prevent readmissions, and increase client satisfaction.

Transitional care interventions often include the following key components:

  1. Assessment and planning: A thorough evaluation of clients’ needs, preferences, and resources is conducted to develop an individualized care plan that addresses their unique requirements during the transition.
  2. Communication and information sharing: Effective communication among health care providers, clients, and their families is vital. Timely and accurate transfer of medical information, care instructions, and follow-up plans helps ensure continuity of care and prevent errors.
  3. Medication management: Reviewing and reconciling medication lists, addressing any changes in medications, providing clear instructions, and promoting adherence are crucial in preventing medication errors and adverse events during transitions.
  4. Care coordination: Collaboration and coordination among health care providers, including nurses, primary care physicians, specialists, and other team members, help ensure a seamless transition and continuity of care.
  5. Client and family education: Empowering clients and their families with the knowledge and skills needed to manage their health conditions, recognize warning signs, and navigate the health care system effectively promotes self-care and reduces the risk of complications or readmissions.
  6. Follow-up and monitoring: Establishing appropriate follow-up appointments, monitoring client progress, and ensuring access to support services or resources contribute to ongoing care and prevent gaps in care.

Transitional care interventions minimize adverse events, promote client safety, enhance client satisfaction, and improve health outcomes during care transitions. Transitional care recognizes the importance of maintaining continuity and coordination throughout the health care journey to facilitate a seamless and client-centered health care experience. Table 30.1 compares transitional care interventions.

Transitional Care Care Transition Care Coordination
Definition The process of transferring clients’ care between health care providers or settings, ensuring the continuity of care, and promoting client safety The movement of clients between health care settings or levels of care (e.g., hospital to home, hospital to long-term care facility) The process of organizing and coordinating health care for clients, involving collaboration between health care providers, clients, and their families
Focus Coordinating the handoff of care during transitions to optimize client outcomes and avoid medical errors Ensuring a smooth and safe transfer of care as clients move between different health care settings Coordinating the delivery of health care services to ensure continuity and effective care for clients
Table 30.1 A Comparison of Transitional Care Interventions

Care Transitions

Care transitions are critical junctures in health care where individuals move from one health care setting to another or experience changes in their care needs. In the community setting, transitions of care encompass a wide range of scenarios.

Some common types of transitions include:

  • Hospital to Home: This transition often requires careful planning to ensure that clients receive the necessary support and resources to manage their health conditions at home (Figure 30.2).
  • Home to Long-Term Care: Transitions from home to long-term care settings, such as nursing homes or assisted living facilities, may occur when individuals require a higher level of assistance or specialized care that cannot be adequately provided in their homes. These transitions involve coordination between home care services, long-term care facilities, and families to ensure a smooth transfer of care.
  • Rehabilitation or Subacute Care: Transitions to rehabilitation or subacute care facilities are common when individuals require intensive therapy, post-surgical care, or recovery support following an acute illness or injury. These transitions involve coordinating the transfer of medical information and care plans between acute care hospitals and rehabilitation facilities.
A nurse pushes a client in a wheelchair through a set of doors. Another nurse walks next to them, holding a sign that says Wish You Well.
Figure 30.2 Nurses are involved in the transition of care when clients are discharged from hospitals to their homes. This photo depicts the discharge of a veteran who spent 50 days in a VA hospital recovering from COVID-19. (credit: “Arvin McCray, first COVID-19 patient goes home aft 50 days” by Milwaukee VA Medical Center/Flickr, Public Domain)

The quality of the care transition can have an impact on clients, families, and health care providers.

  • Client Outcomes: Effective transitions of care positively influence client outcomes, leading to improved health outcomes, reduced hospital readmissions, and enhanced quality of life. Well-coordinated transitions support medication adherence, timely access to follow-up care, and effective self-management.
  • Family Involvement and Support: Transitions of care affect not only clients but also their families, who play a crucial role in supporting the transition process. Inadequate support or coordination can result in caregiver burden, stress, and challenges in managing the care needs of their loved ones.
  • Nurses and Other Health Care Providers: Transitions of care impact all health care providers by requiring effective communication, collaboration, and coordination. Nurses must ensure accurate transfer of information, address client and family concerns, and support clients during the transition process.

Care Coordination

Nurses are central to care coordination efforts, utilizing their unique knowledge, skills, and expertise to facilitate the delivery of comprehensive and seamless care as clients move between different health care settings, ensuring the continuity of care. This process involves sharing critical client information, including medical history, diagnoses, medications, and care plans, with the receiving nurses and other health care providers. This information exchange helps prevent care gaps and gives a comprehensive understanding of the client’s needs, enabling providers to deliver appropriate and timely interventions.

Care coordination involves identifying clients’ specific needs during transitions and making timely and appropriate referrals to other health care professionals or community resources. For example, a community health nurse may coordinate referrals to home health services, physical therapy, or social support services to facilitate a smooth transition and ensure ongoing care and support for the client.

Coordinated care includes medication reconciliation, the process of comparing a client’s medication orders to all the medications that the client has been taking and ensuring that clients have access to necessary medications during transitions. This helps prevent medication errors. Ensuring that clients have a clear understanding of their medication regimen, dosages, and any changes that may have occurred during the transition reduces the risk of adverse drug events and enhances client safety.

Care coordination promotes collaboration and communication among health care providers involved in the client’s care. This collaboration allows for the exchange of information, coordination of treatment plans, and addressing any potential issues or concerns during the transition. By working together, health care providers can ensure a smooth handoff of care and provide consistent and coordinated support to the client. During case conferences or interprofessional team meetings, nurses and other health care providers share information, discuss the client’s current status, review progress, and collaborate on the development of a comprehensive care plan. They can discuss any challenges or concerns, share updates on treatment plans and interventions, and make decisions collectively to ensure an integrated and cohesive approach to care.

Actively engaging clients and their families in the transition process leads to more sustained outcomes. This includes providing education, support, and resources to empower them to actively participate in their care. Involving clients and their families in care coordination enhances their understanding of the transition process, improves adherence to care plans, and promotes self-management skills, ultimately leading to better outcomes. Arranging appropriate follow-up appointments and monitoring the client’s progress after the transition ensures that clients receive timely and necessary post-transition care and support, such as reviewing treatment effectiveness, addressing any concerns or complications, and making any adjustments to the care plan as needed.

Care coordination enhances communication, collaboration, and support among health care professionals, clients, and their families, resulting in improved outcomes, reduced readmissions, and enhanced client experiences during transitions of care.

Factors Contributing to Poor Transitions of Care Outcomes

Many factors can undermine the quality of transitions of care and hinder the achievement of optimal outcomes. Some challenges or risks associated with transitions of care include:

  • Care Coordination Complexity: Coordinating care across different health care settings and multiple providers can be challenging. Lack of care coordination can lead to disjointed care plans, conflicting instructions, and delays in accessing necessary services, which may negatively impact client outcomes.
  • Client and Family Factors: Transitions of care can be overwhelming for clients and their families. The stress of navigating new care settings, understanding care plans, and managing medications can contribute to anxiety, confusion, and nonadherence to treatment plans.
  • Transitional Care Vulnerabilities: Vulnerable populations, such as older adults, individuals with low health literacy, individuals who are economically insecure, and those with limited social support, face additional challenges during transitions of care. They may have difficulties accessing resources, paying for resources, understanding care instructions, or advocating for their needs.

Communication Breakdown and Limited Health Literacy

Communication breakdowns contribute to poor transitions of care outcomes in several ways. One significant factor is the incomplete transfer of client information between health care providers and settings. Vital details, including medical history, diagnoses, medication changes, and care plans, may be inaccurately documented or omitted, leading to a fragmented understanding of the client’s needs and potential risks during the transition.

Limited health literacy contributes to poor transitions of care outcomes. Health literacy refers to an individual’s ability to obtain, understand, and use health information to make informed decisions and navigate the health care system. When health literacy is limited, individuals may struggle to comprehend medical instructions, follow medication regimens, or engage in self-care, leading to suboptimal management of health conditions during transitions of care.

The absence of standardized communication tools and processes is another challenge. Varying documentation formats, inconsistent terminology, and limited guidelines for handoffs hinder effective information exchange, resulting in misunderstandings, misinterpretations, and vital information being lost in translation.

Transitions of care involve multiple health care professionals working together, but communication breakdowns can occur. Competing responsibilities, inadequate communication channels, and ambiguity regarding roles and responsibilities contribute to confusion, decision-making delays, and missed collaboration opportunities.

Effective communication with clients and their families is vital during transitions of care. Inadequate information sharing, limited health literacy, and cultural or language barriers hinder effective communication, impede understanding, and contribute to gaps in care and medication mismanagement.

Technological barriers also pose challenges. The use of electronic health records (EHRs) and other health information systems, if not optimized for effective communication, can impede the seamless transfer of information. Incomplete or inaccurate data entry, interoperability limitations, and suboptimal user interfaces can hinder the exchange of information between health care settings and providers.

Addressing these communication breakdown factors is crucial. Standardizing communication tools, improving documentation practices, enhancing interprofessional collaboration, involving clients and families, and optimizing health information technology can mitigate communication breakdowns and promote effective communication during transitions of care. By doing so, health care providers can enhance client safety, improve outcomes, and ensure continuity of care throughout the health care journey.

Care Fragmentation

Care fragmentation refers to a lack of communication, collaboration, and integration among various health care entities involved in an individual’s treatment and management. This fragmentation can occur at multiple levels, including within health care systems, between different health care settings (such as hospitals, primary care clinics, and specialty clinics), and across different providers involved in a client’s care.

The impacts of fragmentation of care on health outcomes are profound and far-reaching. Firstly, fragmented care can lead to delays in diagnosis and treatment, as information and medical records are not easily shared or accessible between different health care providers. This can result in missed or delayed interventions, which can have serious consequences for clients, particularly those with chronic or complex conditions.

Secondly, the lack of coordination and continuity in care can lead to duplicated or conflicting interventions, unnecessary tests, and medication errors. Without a centralized system to track and manage a client’s health care journey, providers may not have a comprehensive understanding of the client’s medical history, resulting in suboptimal decision-making and potential harm to the client.

Moreover, fragmentation of care can negatively impact client engagement and empowerment. When clients are shuttled between different providers and settings, they may feel disconnected from their care and struggle to navigate the complex health care system. This can lead to frustration, confusion, and a decreased sense of ownership over their health, ultimately hindering their ability to actively participate in their own care.

Furthermore, fragmented care poses challenges for comprehensive management of chronic diseases. Clients with multiple comorbidities often require the involvement of various specialists and health care professionals, but the lack of coordination can result in fragmented treatment plans and inadequate attention to the client’s health needs. This can contribute to suboptimal disease management, poorer health outcomes, and increased health care costs.

Social Determinants of Health and Health Disparities

Social determinants of health (SDOH) are the nonmedical factors that significantly influence health outcomes and disparities. They include socioeconomic status, education and health literacy, social support networks, housing and environment, and access to health care. As discussed in Social Determinants Affecting Health Outcomes, disadvantaged socioeconomic status often translates into reduced access to quality health care, limited transportation options, and financial constraints, all of which impede seamless transitions of care. For example, individuals with lower incomes may be unable to afford necessary medications or follow-up appointments, resulting in interrupted continuity of care and increased health risks.

Health disparities, which are systemic differences in health outcomes among different population groups, exacerbate the challenges faced during transitions of care. Disadvantaged communities, including racial and ethnic minorities, individuals with disabilities, and older adults, often experience higher rates of chronic diseases and face barriers to accessing health care services. These disparities can stem from structural and social determinants of health, such as discrimination, inadequate health care infrastructure, and limited availability of culturally responsive care. Consequently, individuals from these populations are more likely to encounter difficulties during transitions of care, leading to poorer health outcomes.

SDOH have a significant impact on transitions of care and creates a complex web of challenges that contribute to poor transitions of care outcomes. Efforts to improve health literacy through educational initiatives and enhanced communication strategies are crucial in empowering individuals to actively participate in their care during transitions. Additionally, addressing SDOH including health disparities requires comprehensive interventions, such as equitable health care policies, improved access to affordable health care, and culturally responsive care delivery. By addressing these interconnected issues, health care systems can strive to minimize the impact of SDOH and improve transitions of care outcomes, leading to better health outcomes for all individuals. Table 30.2 summarizes the factors that contribute to poor transitions of care outcomes.

Factors Description Contributing Factors
Communication Breakdown Inadequate exchange of information between health care providers and settings
  • Lack of standardized communication protocols and channels
  • Insufficient transfer of medical records
  • Incomplete or delayed transmission of client information
  • Language barriers
  • Misinterpretation of information
Fragmented Health Care Disjointed care delivery and coordination among multiple providers
  • Lack of care coordination mechanisms
  • Inadequate collaboration between health care providers and settings
  • Fragmented electronic health records (EHR) systems
  • Inefficient handoffs and referrals
  • Poor integration of primary care and specialty care
Medication Errors Errors in medication reconciliation, prescription, or administration
  • Inaccurate medication histories
  • Lack of standardized medication reconciliation practices
  • Inadequate client education on medication management
  • Illegible or incomplete prescriptions
  • Lack of medication reconciliation during care transitions
Limited Client Engagement Insufficient involvement of clients in their own care
  • Limited health literacy and understanding of care processes
  • Lack of client empowerment and shared decision-making
  • Inadequate client education on self-management and care transitions
  • Limited access to health care information and resources
  • Cultural or language barriers affecting client engagement
Inadequate Follow-Up Care Insufficient support and monitoring following the care transition
  • Delayed or missed appointments
  • Lack of clear discharge instructions
  • Inadequate care coordination between settings and providers
  • Limited access to necessary follow-up services or specialists
  • Lack of timely communication regarding test results and treatment plans
Socioeconomic Factors The interaction of social and economic factors that influence care transitions
  • Limited access to health care services due to financial barriers
  • Unstable housing or homelessness
  • Lack of social support and resources
  • Low health literacy and limited knowledge of available resources
  • Transportation barriers
Table 30.2 Factors Contributing to Poor Transitions of Care Outcomes

To address communication breakdowns during transitions of care, several strategies can be implemented:

  • Standardizing Communication: Health care organizations should adopt standardized communication tools, such as structured handoff protocols like SBAR (Situation, Background, Assessment, Recommendation) to ensure a consistent and comprehensive transfer of information, enabling effective communication during transitions.
  • Improved Documentation Practices: Encouraging accurate and detailed documentation of client information, medication lists, and care plans supports effective information exchange. The use of electronic health records with standardized templates can facilitate consistent and comprehensive documentation practices, minimizing the risk of vital information being overlooked or misinterpreted.
  • Enhancing Interprofessional Collaboration: Establishing clear communication channels, holding regular team meetings, and implementing shared decision-making frameworks help prevent communication breakdowns and enhance collaboration. By fostering a culture of effective communication, health care providers can ensure a smooth and coordinated transition process.
  • Client and Family Involvement: It is vital to actively engage clients and their families in the transition process via client education, shared decision-making, and clear communication. Using plain language, providing written materials, and considering cultural and linguistic factors contribute to client engagement and mitigate communication barriers. By involving clients and families as partners in care, health care providers can improve understanding, promote adherence, and promote successful care transitions.
  • Technology Optimization: Health care organizations should prioritize the optimization of health information technology. This includes ensuring interoperability between different systems, implementing user-friendly interfaces, and enabling comprehensive data-sharing capabilities. By optimizing technology, health care providers can facilitate seamless communication, reduce errors, and improve the exchange of information during transitions of care.

Transitional Care Improves Health Outcomes

Transitional care, when effectively applied, can significantly improve health outcomes for clients. This integrated and coordinated approach ensures that clients receive the care they need, when they need it, and in a way that they understand. It is a comprehensive, person-centered, and evidence-based approach that facilitates the safe and timely movement of clients between levels and locations of health care. Effective transitional care is characterized by continuity of care, regular follow-ups, personalized care plans, client and caregiver education, medication reconciliation, and careful scheduling of appointments. It promotes improved communication between health care providers across different settings, reduces hospital readmissions, and decreases health care costs.

For the client, effective transitional care feels supportive, well-coordinated, and tailored to their unique needs. They experience a seamless transition between care settings with no unnecessary repetition of medical histories, tests, or procedures. Clients receive education about their conditions and medications, and they are encouraged to be active participants in their care, which enhances their sense of control and responsibility for their health outcomes.

Case Reflection

Transistional Care

The following scenario provides more information on Mrs. Johnson from the chapter-opening scenario. Read the scenario, and then respond to the questions that follow.

Seventy-two-year-old Mrs. Johnson was hospitalized for congestive heart failure. When discharged, she was still in a fragile state, prone to potential health complications. However, through effective transitional care, Mrs. Johnson’s transition from hospital to home was planned and coordinated by a dedicated team, ensuring she was not left to navigate her recovery alone. Mrs. Johnson’s transitional care started with a clear and comprehensive discharge plan detailing her medications, diet, and activity levels, ensuring she understood her condition and treatment. The team explained the plan to both Mrs. Johnson and her family, giving them all a chance to ask questions and clarify the plan of care. A registered nurse followed up with Mrs. Johnson within 48 hours of discharge, answering questions and addressing any immediate concerns. The care plan included scheduled check-ups with her cardiologist and primary care physician, a visiting nurse service, and connection to a heart failure support group.

Mrs. Johnson’s medication was reviewed and reconciled, reducing the risk of medication errors. She was also provided with a 24/7 contact number in case of emergency or if she had any questions about her care. Mrs. Johnson and her family felt supported and empowered, leading to her adherence to her care plan and ultimately resulting in a quicker recovery and significantly lower risk of readmission. Effective transitional care, such as the care Mrs. Johnson received, leverages the strengths of an interprofessional approach, promoting better health outcomes, improving client experience, and reducing health care costs. As the health care system moves toward a more integrated and person-centered model of health care, optimized transitional care is becoming an integral part of the journey toward better health for all.

  1. Why is effective transitional care essential for clients like Mrs. Johnson, who have chronic conditions such as congestive heart failure?
  2. What are some of the benefits of using an interprofessional approach to plan and coordinate transitional care? How does this approach improve client outcomes and reduce health care costs?
  3. What are some potential barriers that may arise when implementing effective transitional care plans?
  4. How can nurses address these barriers to ensure clients receive the best possible care?

Healthy People 2030

Health Communication

Healthy People 2030 focuses on improving health communication so that people can easily understand and act on health information. Health information and messages are often overly complex, making them hard to understand and use. Health care providers who communicate clearly and use methods like teach-back and shared decision-making can help people make informed health-related decisions. Teach-back involves asking the client or family to explain in their own words what they need to know or do about the client’s health. These strategies can help improve outcomes, especially for certain groups—like people who have limited health literacy skills or speak English as a second language.


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