It Takes a Team – WSNA

Transitional care encompasses a wide range of services and environments designed to promote the safe and timely passage of patients between levels of health care and settings of care.

Gaps can arise in this process, including poor communication, incomplete transfer of health information, lack of essential services in a community, inadequate education upon discharge, complicated financial reimbursements, regulatory constraints and barriers literacy, linguistic or cultural.

Unfortunately, gaps in transitional care planning can lead to readmissions and adverse events. A 2022 review by the Agency for Healthcare Research and Quality (AHRQ) of patients discharged directly to home or community care found that “about one in five hospitalized patients are readmitted within 30 days and a third of patients are readmitted within 90 days.”

About half of older adults transitioning from hospital to community settings were affected by at least one medical error, and 20% were affected by one or more adverse events. Low socioeconomic status predicted a particularly high risk of poor outcomes, such as medication errors, injuries, and higher hospital readmission rates.

According to a 2019 JAMA article, discharges to skilled nursing facilities fared somewhat better, but were more expensive. “Among Medicare beneficiaries eligible for post-acute care at home or in a skilled nursing facility, returning home with home health care was associated with higher readmission rates, with no detectable difference in mortality or functional outcomes and lower Medicare payments.”

So what can you do? Nursing care is essential to your patient’s well-being in the facility. The trust you have developed with family and caregivers makes you an important part of a safe transition of care plan! Since discharge planning begins at admission, here’s how to help:

  • Use good communication skills and include family caregivers. For a quick review, check out the American Association of Critical Nurses’ blog on shifting the focus to families. A good resource with COVID talking points in different languages ​​is the COVID Ready Communication Playbook from
  • Mobilization: Mobilization is a key measure that RNs can take to prevent deconditioning of patients. Hospitalized patients, who were independent prior to admission, lose function at a staggering rate during their hospital stay. Without mobilization and conditioning, patients may be unable to return home and require stay in a skilled nursing facility.
  • Reinforce discharge care plan. Refer to the AHRQ guide, “Caring for Me: A Guide for When I Leave the Hospital,” or other materials provided by the facility.
  • Know your fthe facility’s care transition staff. Keeping up with regulations, community resources, and payment processes is daunting. Facility staff are the experts in transition work, sometimes based on requirements or recommendations from AHRQ’s Centers for Medicare and Medicaid Services (CMS).
    Provide help by knowing some of the information they will need and coordinate efforts. (See the Washington State Hospital Association’s two-page “Hot Transfer Guide”).
  • Review regulations or legal documents (such as power of attorney, guardianship, portable medical orders, etc.) for health care decisions that could be barriers to transfer out of the facility. (For example, a minimum stay of three days is required for admission to a qualified nursing facility covered by paid Medicare.)
    Also, it is important for families to know that medical insurance does not pay child care costs. Child care is paid for out of pocket, by long-term care insurance, or by Medicaid. In many cases, patients with resources must spend their resources on their own care to be eligible for Medicaid.

It takes a team to develop and reinforce a safe care transition plan: you, the patient, family caregivers and your care transition professionals.

The WSNA continues to seek opportunities for safe staffing in healthcare facilities. We know, and research backs it up, that inadequate nurse staffing leads to medical errors, poorer patient outcomes, nurse burnout, and nurse injuries.

Our Nursing Quality Assurance Commission submitted the final report on long-term care workforce development in June 2021, and this important document helped advise state governors’ budget. Washington, which now includes provisions to address the nursing shortage and long-term care crisis.

As nurses, we need to stay informed and continue the important work of advocating for our patients and ourselves. Take a step forward and learn more about care transitions.W

Karla Hall, BSW, BSN, RN, CCM, contributed to this article.

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