As a nurse, you’ve been involved in countless care transitions with other members of the interdisciplinary team. Each time you transfer a patient, you fulfill three important roles — the voice of the patient, the source of patient information for other team members, and the transition coordinator. But some transitions are more successful than others, especially when patients leave acute care facilities to go to skilled nursing facilities (SNFs), other residential facilities, or their own homes.
It’s unfortunately true that, sometimes, transferring a patient out of your care becomes a disjointed process. Team work may break down, ultimately impacting the quality of care the patient receives. But as your patient’s #1 advocate, you can take steps to work with other members of the interprofessional care team, ensuring patient transitions are completed in as safe and timely a manner as possible.
The Joint Commission (TJC) names seven foundations for safe, effective patient care transitions from acute care to another healthcare setting. These foundations help build best practices for all nurses, regardless of practice area:
Putting these foundations into practice helps reduce readmissions and decreases emergency room visits. Patients are also more likely to give high satisfaction scores and be more compliant with their care plans. And caregiver competence is improved when these foundations are used during the transition process.
For a safe patient transition to occur, each member of the care team must be committed to:
As a nurse, your role in care transitions should focus around six best practices: