The key components in developing a successful Care Transitions Program include the following:
- Begin discharge planning before the patient is admitted. …
- Coordinate with case manager during inpatient stay. …
- Reinforce discharge plan and instructions. …
- Medication Reconciliation. …
- Develop and implement a follow-up/outreach plan
- Transitional Care Planning is a patient-centered, interdisciplinary process that begins with an initial assessment of the patient’s potential needs at the time of admission and continues throughout the patient’s stay.
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The aims of the care transitions program were to (1) educate patients about their health condition, including red flags, and teach self-monitoring of chronic disease; (2) perform a medication reconciliation and create an up to date medication list; (3) ensure timely physician follow up; (4) provide a patient-centered .
