Transition care is a “bridging strategy” that hospitals could recommend to reduce post-discharge complications including infections, aspiration, adverse drug effects, disability and mortality. Studies indicate, nearly one lakh elderly patients are re-admitted every year due to adverse drug effects. – by Dr Vijay Janagama Director, New Initiatives, SuVitas Holistic Healthcare

Medical science is essentially a partnership of trust and faith among the physician and patient. However, the sacrosanct relationship has been facing several challenges in the recent times. A lack of clear way forward plan after discharge might severely hit the overall quality of care due to decreased patient compliances. While it may take a bit longer to tackle the many reasons attributed for this, one of the main accusations hospitals is being charged can be prevented with a patient-centric care strategy. Early transition care can significantly cut down the 30-day readmission rates in elderly and particularly in patients recovering from chronic ailments.

Early transition care refers to the continued and coordinated care provided to a patient recovering from an acute illness, soon after discharge until he is shifted to home. Specialized short-term stay programmes are provided by a multidisciplinary team of medical professionals to help patients regain functional independence and enhanced recovery. Along with continuous medical supervision, a transition care setting is equipped with a broad range of rehabilitation interventions, designed in accordance with the changing needs of the patient, to prevent unnecessary readmissions, adverse events and expenditure. Patients recovering from conditions like stroke, spinal cord injuries, head injuries, cardiac disorders, demyelinating diseases, chronic obstructive pulmonary diseases, neuromuscular disorders etc. will need extended care before being shifted to an outpatient setting.

Stroke patients for instance, will need rigorous monitoring for up to three months after hospital discharge in order to completely move out of the danger zone. It is quite impractical for hospitals to provide its facilities throughout the recovery journey of a patient since priority must be given to those needing acute care. Thus, hospitals can work with transition care facilities to offer dedicated ambulatory care to patients until they are fully ready to go home. In an ideal care setting, transition care must begin right at the intensive facility itself where a rehabilitation team works with the intensivist. This approach will help in the optimal recovery of a patient. Followed by a structured discharge communication, a patient is transferred to a dedicated inpatient rehabilitation care setting where extended medical care is offered until complete recovery. While a average stay in a rehabilitation center is between 4 to 7 weeks, depending on the severity of the condition a longer duration may be recommended.

Hospitals can reduce readmissions in patients by placing an effective communication mechanism between caregivers, transition care providers, patients and their family. Based on the age, previous medical history and the pace of recovery of the patient, the doctor at a hospital can work with a rehabilitation team to decide on an appropriate care plan. Accordingly, the discharge plan will be made in close discussion with the patient and his family. This will help in overcoming any communication breakdowns that could negatively affect the patient’s health in future. Even after shifting the patient to a transition care facility, the primary caregiver at the hospital will continue to play a pivotal role in the course of rehabilitation treatments. All clinical decisions with respect to rehabilitation interventions are made in close discussion with the doctor and any signs of improvements or deviations are duly updated.

It takes a mountain of work to save someone’s life. Despite all the concerted efforts of medical staff at hospitals, improper post-hospital care can land high-risk patients back in the hospital beds, often in really bad conditions. A seamless transition care model benefits not just the patient and the family, but the entire medical circle too. A reinforced collaborative approach will present shared accountability for system performance and implementation of best practices. The expertise and efforts of the caregiver are acknowledged and their role in providing integrated care for the optimal recovery of the patient is recognized. Early transition care will thus ensure all resources of the healthcare system are effectively used to enhance the overall quality of care.


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