MANAGING CARE TRANSITIONS

45% of medication errors occur at a point of transition in care. What can I do to enhance care transitions as we prepare for PDPM?


The American Geriatric Society defines a care transition as “A set of actions designated to ensure the coordination and continuity of health care as a patient transfers between locations and encompasses both the sending and receiving aspects of the transfer”. Poor or ineffective transitions can be detrimental to the resident and negatively impact SNF metrics such as census and quality measures. As we prepare for PDPM, now is the time for SNFs to internally examine their processes for both upstream and downstream care transitions for efficiency, thoroughness and efficacy.


Characteristics of a solid care transition

  • Involving the entire continuum

  • Engaging the resident and caregivers

  • Assessing risk for readmission

  • Following a standardized procedure

  • Planning timely follow-up post-discharge

  • Performing root cause analysis on all readmissions


Key considerations for an effective care transition

When developing your standardized procedure for care transitions, be sure your process takes all key areas into consideration.