How can you coordinate care during care transitions?

The healthcare journey of patients is of utmost importance, and coordinating care during transitions plays a vital role in ensuring a seamless experience. By implementing care transition plans, establishing communication channels, leveraging technology, engaging patients in care decisions, and providing them with resources, healthcare providers empower patients to take an active role in their healthcare. Regular follow-up assessments and feedback mechanisms contribute to refining care coordination processes, ensuring that patients receive care that is centered around their needs. patient-centric approach during transitions.

The NHS's Transitional Care Model exemplifies coordinated care during care transitions. This model promotes seamless care coordination between hospitals, community services, and patients, ensuring continuity of care and improving patient outcomes. By thoroughly assessing patient needs and risks and utilising validated tools, healthcare professionals can ensure that patients receive the most appropriate and coordinated care during care transitions. This can lead to improved patient outcomes, reduced readmission rates, and enhanced satisfaction.

Conducting a risk assessment in coordination with the transition of care for clients is crucial for ensuring their safety and well-being during a vulnerable period of change. This process helps in identifying potential risks to the client, including the risk of relapse, harm to self or others, and the exacerbation of symptoms, enabling healthcare providers to implement appropriate safeguards and support systems. By thoroughly evaluating the client's current condition, history, and support network, clinicians can tailor the transition plan to address specific needs and risks, ensuring continuity of care. This approach facilitates a transition between care settings, promotes adherence to treatment, and reduces adverse outcomes.

The most important Objective is getting a smooth transition between the different sectors e.g. outpatient office based and inpatient hospital system. Digitization can contribute a huge value to this process for instance by implementing an electronic health record system. In addition a complete discharge management is the key.

evaluate and improve the care transition process, and identify the gaps, barriers, or challenges that may affect the quality and outcomes of your patients. You should collect and analyze data on the process and outcome measures, such as readmission rates, patient satisfaction, or medication reconciliation.

Conducting a needs and risks assessment for the family unit, in addition to the patient, is essential. Every patient is unique, and having a grasp on everyone that comprises the support system for the patient, and their level of involvement in the patient's care, helps to ensure proper education is provided. Creating space for the family to share their concerns, fears, apprehensions, and hopes, can provide insight into key areas in need of reinforcement, additional education, and follow-up, with their unique learning preferences in mind. Establishing a system to facilitate clear communication between the members of the interdisciplinary team is beneficial, as it promotes timely information sharing as the patient's health status evolves.

Organizar e monitorar o suporte pós-alta é vital para evitar reinternações e garantir uma recuperação segura. Isso inclui arranjos para acompanhamento médico, medicamentos, terapias, e serviços de apoio domiciliar, se necessário. Monitorar o paciente após a alta ajuda a identificar e resolver rapidamente quaisquer problemas ou complicações. A utilização de checklists e sistemas de acompanhamento pode auxiliar neste processo, garantindo que nenhum aspecto importante seja negligenciado.

Scope your efforts to align with community resources and capabilities. Many outpatient clinicians cannot break their schedule to take a phone call. A good quality follow up process that can be done dependably is better than a superior quality follow up process that can only be done intermittently.

Avaliar e melhorar continuamente o processo de transição de cuidado é fundamental para a qualidade e segurança do paciente. Isso envolve analisar regularmente os resultados das transições, identificar áreas de melhoria, e implementar mudanças baseadas em evidências. Feedbacks de pacientes e familiares podem ser valiosos nesta avaliação. O objetivo é desenvolver um processo de transição que seja eficiente, seguro, e centrado no paciente.

Após a alta hospitalar é fundamental a monitorização da evolução clínica do paciente. Enquanto internado, o paciente tem seu sinais vitais medidos de maneira recorrente. Já no domicílio os dispositivos vestíveis (Wearables) podem medir em tempo real sinais vitais como temperatura, ritmo cardíaco, pressão arterial, saturação de oxigênio e outros indicadores fisiológicos. A alteração destes parâmetros pode indicar evolução desfavorável e necessidade de readmissão hospitalar. Toda curva de sinais vitais pode ser monitorada por central de Telessaúde com parâmetros e alarmes pré definidos, garantindo maior segurança no período de transição de cuidados após alta hospitalar.

O uso de tecnologias e ferramentas digitais pode aprimorar significativamente a coordenação do cuidado. Isso inclui sistemas de prontuários eletrônicos, plataformas de telemedicina, e aplicativos móveis de saúde. Essas tecnologias facilitam a comunicação entre a equipe de cuidados e o monitoramento do paciente, oferecendo acesso rápido a informações atualizadas e permitindo intervenções oportunas. É importante garantir a segurança dos dados e a fácil usabilidade dessas ferramentas.