Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings, as well as across health states and between providers. The care settings can include hospitals, Homecare, Long-term Care (LTC) Centers, Rehab Centers, and Skilled Nursing Facilities (SNF).
Well-executed transition of care is essential to delivering the best patient-centered care. It should include a comprehensive care plan to ensure care coordination and continuity with the patient and their family at the critical turning points in care and settings. However, during the physical transition of the patient, large gaps in care may result in coordination breakdowns due to lack of communication and insufficient education or follow-through of the next steps. This can lead to adverse events, unmet needs, low satisfaction with care, and high rehospitalization rates. Ultimately, the mismanagement of turning points can result in impact readmission penalties, ratings, and outcomes.
The National Transitions of Care Coalition (NTOCC) focuses on developing policies, tools, resources, and recommended actions/processes to guide and support providers and patients in achieving effective transitions of care. The NTOCC evaluates current models and seeks to improve the transition of care process. According to the NTOCC, the following problems have been identified as main catalysts to the ineffectiveness of transition of care:
- Breakdown in communication between provider caregivers
- Patients’ inability to adhere to plan
- Lack of procedures insufficient processes
With the increase in the aging population, more and more patients will face a turning point in their care and require better transition of care processes, reflective of the best patient-centered care.
Virtual care technology can enhance the transition of care by enabling providers, patients and family members to better communicate in real-time. It can assist with:
- Limiting disruption to your care teams’ workflows
- Reducing travel time and costs for all care team members
- Aligning timing and process for admissions and transfers
- Minimizing patients’ wait times during critical transition points
Each key stakeholder involved in the transition of care can benefit from using a virtual care platform. As coordinating conversations across a patient’s care team is difficult with busy schedules and various locations, a virtual care communication platform enables providers to connect with each other and the patient, regardless of location and the patient’s stage in the treatment plan. During the video-based calls, clear, efficient and open communication can take place amongst care team members and across locations, maintaining quality of care at all touchpoints throughout the transition of care. The initial providers can share the detailed care plans to those continuing the care after the transfer of the patient. Questions can be answered in real-time and all involved can observe visual cues signifying that everyone is aligned on their respective roles and responsibilities. The patient’s family can also be included – along with home health nurses who may be continuing to provide care if the patient is transitioning to one’s home. Once the patient is transferred, providers can follow-up via virtual visits to ensure patient adherence to the medical plan. The use of virtual care can ensure that patient-centric care is the focus of all providers and institutions delivering care at each turning point.