Transitional care: Care involved when a patient/client leaves one care setting (i.e. hospital, nursing home, assisted living facility, SNF, primary care physician, home health, or specialist) and moves to another.
Specifically, they can occur:
- Within settings; e.g., primary care to specialty care, or intensive care unit (ICU) to ward.
- Between settings; e.g., hospital to sub-acute care, or ambulatory clinic to senior center.
- Across health states; e.g., curative care to palliative care or hospice, or personal residence to assisted living.
- Between providers; e.g., generalist to a specialist practitioner, or acute care provider to a palliative care specialist
Transitions of care are a set of actions designed to ensure coordination and continuity. They should be based on a comprehensive care plan and the availability of well-trained practitioners who have current information about the patient’s treatment goals, preferences, and health or clinical status. They include logistical arrangements and education of patient and family, as well as coordination among the health professionals involved in the transition.
(www.ntocc.org)
What do we mean by “Care Transitions”
The term “care transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. For example, in the course of an acute exacerbation of an illness, a patient might receive care from a PCP or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition.
(www.caretransitions.org)