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30.1 The Effects of Care Coordination and Care Transitions on Outcomes

Transitional care is as a process that supports clients as they move between different health care settings, ensuring continuity and safety. Factors contributing to poor transitions of care outcomes include communication breakdown, care fragmentation, limited health literacy, socioeconomic factors, and health disparities. Transitional care promotes seamless and well-coordinated care, reducing medication errors, preventing readmissions, and enhancing client engagement. By understanding the importance of effective care coordination and transitions, health care professionals can strive to optimize client outcomes and overall health care system performance.

30.2 Care Transition Models

Care transition models are frameworks designed to facilitate smooth transitions of care. Commonly used models include CTI, TCM, and BOOST. Each model aims to ensure that clients can receive appropriate and coordinated care during the transition process. Discharge planning helps ensure a smooth transition for a client from a hospital or other health care setting to their home or another facility. The IDEAL Discharge Planning guide engages clients and their families, emphasizing the importance of client-centered care, effective communication, and education.

30.3 Role of the Community Health Nurse

CHNs play a crucial role in improving outcomes and safety during care transitions through the incorporation of evidence-based interventions. CHNs may use a variety of strategies to enhance safety and continuity of care for clients transitioning from behavioral health hospitalization to outpatient care, with each emphasizing the importance of a comprehensive and client-centered approach. CHNs contribute to enhanced quality through care coordination and transition management by promoting effective communication, client engagement, and seamless transitions. Utilizing electronic health, mobile health, and telehealth systems facilitates coordination and transitions of care. A collaborative approach in coordinating care with other health care professionals and concerned parties ensures comprehensive and coordinated client care.


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