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This session will discuss key factors leading to ineffective care transitions, emphasize the need for a new approach to delivering transitional care, and describe an integrated approach to achieve optimal transitional care. This approach is based on best practices of different models of care transitions and has not been implemented yet. It has seven key elements based on factors that can help achieve effective care transitions: (1) effective communication among providers; (2) discussion of goals of care and advance directives; (3) functional assessment; (4) medication reconciliation; (5) co-ordination and effective implementation of a care plan; (6) timely and quality discharge summaries; (7) patient-centered instructions and risk-related education.
Learning Objectives: (1) Implement key elements of an effective care transitions into patient care. (2) Establish strong communication and collaboration with community physicians, and hospital, and home care teams to provide optimal patient care during care transitions. (3) Implement strategies for effective communication with patients, families and care teams during care transitions.
