your path: Home > Public Education > PEF Listing >

Patient Education Forum Transitional Care By Eric A. Coleman, MD, MPH University of Colorado Health Sciences Center

Download in PDF format

What is Transitional Care?

Older adults who suffer from a variety of health conditions often need health care services in different settings to meet their many needs. "Transitional Care" refers to when they move across settings. When they "transition" they often are treated by many different health care professionals.

What Types of Problems Occur When Transitions Are Poorly Managed?

During transitions, older patients are at risk for medication errors and for not receiving the right services. They may end up in the hospital or in the emergency room because of the poor care they received during their transition. After leaving a particular care setting, older patients may not understand how to manage their health care conditions or who to call if they have a question or if their condition gets worse. Poorly managed transitions can lead to physical and emotional stress for both patients and their caregivers. During a transition, the patients' preferences or personal goals in one setting may not be passed on to the next setting. This may result in important elements of the care plan "falling through the cracks".

What Can I Do to Ensure that My Transitions Go Smoothly?

Although health care practitioners in different settings should communicate with one another, it is a good idea to take steps to make sure that each health care professional has the information they need about your conditions and your treatments. The following are steps that you and your caregiver can take:

• Keep your own personal file of important health information and show this to each new health care professional. You should keep a list of your health conditions, the names and phone numbers of your health care professionals, medications you are taking, and any allergies that you may have.
  
  
• Take charge of your medications (both prescribed and over-the-counter) and know why you take each one, how to take each one, and any possible side effects to watch for.
  
  
• Make sure that you understand what services you will get at each new setting and how these will benefit you. Once you arrive at each new setting, let people know your preferences and ask that these become part of your overall care plan. Bring a friend or relative with you to be your advocate.
  
  
• Before leaving each setting, write down the name and telephone number of the health care professional you can contact if you have any questions or should your condition get worse.
  
  
• Before leaving each setting, ask what type of follow-up care you will need and how this will be scheduled.
  
  
• Schedule an appointment with your primary care physician or case manager to discuss how your needs would be met if you could not care for yourself for a few days or long-term. Planning ahead and knowing what Medicare (and any other insurance you may have) covers is a positive step towards making sure that any future transitions go smoothly.

Where Can I Find More Information?

http://www.caretransitions.org
http://www.caregiving.org
http://www.Medicare.gov or 1-800-Medicare
http://www.jcaho.org/

Provide feedback on this PEF