You're overseeing a patient's care transition. How do you ensure their continuity of care remains seamless?

The key here is communicate, communicate, communicate. Communicate early, frequently, and schedule a follow up in advance of each deadline. Keeping the client in the loop about what steps are active and which are pending reduces their overall stress and supports them in the process. Doing good follow up with the rest of the team keeps the case moving forward and allows improved reaction time to barriers that may come up.

Para garantir uma transição perfeita de cuidados de um paciente, é essencial comunicar de forma clara e detalhada todas as informações relevantes entre a equipe de saúde atual e a equipe que assumirá o cuidado. Isso inclui um resumo abrangente do histórico do paciente, plano de tratamento, medicamentos e necessidades especiais. Além disso, coordene uma reunião de transição entre as equipes, envolva o paciente e sua família no processo para garantir que estejam informados e confortáveis com o plano, e estabeleça um sistema de acompanhamento para monitorar e resolver qualquer problema que possa surgir após a transição.

There's nothing more frustrating than the plan falling apart at the last moment and the patient/client feeling isolated and abandoned. Even in the best practices, things don't always work out. By the patient being involved and having a clear expectation about what barriers MIGHT be from the beginning reduces the stress on the process. Having a workflow that's consistent and making sure both sides of the transition have their needs met in sharing of information (releases of information) and required documentation that meets recommendations for level of care transition will significantly reduce hiccups.

Text is rarely an appropriate communication style, and when it comes to patient care, text is a drop-dead last resort due to privacy and disclosure risks. After that, timeliness demands voice communications, either by phone or face-to-face when possible. If there's a long plan of action or a long-term plan, put it in writing! A phone call can clarify any parts of the written plan and revisions can be made in real-time and resent so that a "contract" of the plan can been agreed upon on both sides.

Step one, release of information, follow your legal and policy requirements for disclosure of information. Step two, minimum necessary rule, only send what is needed. Step three, follow up to ensure everything that is requested is received or accounted for in the transmission of information.

Talk out the steps of transition. Leaving a patient in the dark about their care is a recipe for errors and opens you and your agency to legal and ethical liabilities for violation of privacy rights or permission to transition the patient. Transfer of care is best served when the patient agrees, even if they're court ordered.