What is the process for developing a transitional care plan?

1 Assess the patient's needs

The first step is to assess the patient's medical, functional, social, and emotional needs, as well as their preferences and goals for their care. This can be done by using standardized tools, such as the LACE index, the INTERACT tools, or the CARE tool, or by conducting a comprehensive geriatric assessment. The assessment should involve the patient, their family or caregivers, and the multidisciplinary team of health care providers who are involved in the patient's care.

2 Identify the appropriate level of care

The next step is to identify the most appropriate level of care for the patient based on their needs, preferences, and resources. This may include home health care, home-based primary care, palliative care, hospice care, skilled nursing facility, assisted living facility, or long-term care facility. The level of care should be aligned with the patient's goals and expectations, and should provide the necessary services and support for the patient's condition and recovery.

3 Develop the care plan

The third step is to develop the care plan that outlines the specific goals, interventions, and follow-up actions for the patient's transition. The care plan should be individualized, evidence-based, and patient-centered. It should address the patient's medical issues, medications, self-management skills, education needs, psychosocial needs, and caregiver support. The care plan should also specify the roles and responsibilities of the health care providers, the patient, and the family or caregivers, as well as the frequency and mode of communication and coordination.

5 Monitor and evaluate the care plan

The fifth step is to monitor and evaluate the care plan and the patient's progress and outcomes. This may involve conducting regular follow-up calls, visits, or telehealth sessions with the patient and the family or caregivers, as well as reviewing the patient's clinical data, such as vital signs, laboratory results, or medication adherence. The monitoring and evaluation should also involve collecting feedback from the patient and the family or caregivers on their satisfaction and experience with the transition. The care plan should be adjusted as needed based on the patient's changing needs and goals.

6 Ensure continuity and coordination of care

The final step is to ensure continuity and coordination of care across different settings and providers. This may involve establishing and maintaining a clear and consistent point of contact for the patient and the family or caregivers, as well as sharing relevant information and updates among the health care team. It may also involve facilitating the patient's access to community resources, such as social services, support groups, or self-management programs. The continuity and coordination of care should aim to promote the patient's safety, quality of life, and well-being.

7 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?