Transition of care and the impact on the environment of care

Kerrie S. Guerrero, Susan E. Puls, Dorothy A. Andrew


An unplanned readmission to the hospital within 30 days of discharge is seen as a failure by the healthcare team to appropriately plan for a safe and effective discharge to the next level of care. According to The Center for Medicare & Medicaid Services (CMS), the national average readmission rate in 2012 was 18.4%. As CMS shifts to a pay for performance strategy, a readmission rate higher than the national average for specific disease processes will result in a financial penalty. Many organizations have identified the need to improve the current discharge planning processes and to provide patients with a safer transition to the next level of care to prevent readmissions. Evidence demonstrates that there is value in reconfiguring the current discharge processes toward interventions that demonstrate a reduction in readmission rates. The discharge process should incorporate a multidisciplinary, multicomponent transition of care intervention that starts while the patient is in the hospital and continues with some type of home-care follow-up. Transition of care is a relatively new term that is used to describe a set of interventions designed to coordinate a patient’s care during the movement between healthcare settings. Implementing a well-designed transition of care program allows hospitals to provide a safe Environment of Care to patients during their care transitions. Environment of Care is a term coined by The Joint Commission that is used to describe the environment in which the patient is being cared for. The term usually involves three components: the people, the equipment and tools, and the building. As healthcare changes, it will become increasingly important to provide patients with care management throughout the continuum of care, which means thinking of the patient’s Environment of Care in much broader terms. How do transition of care processes affect the patient’s Environment of Care? Does a well-implemented transition of care program lead to a positive impact in the patient’s overall Environment of Care? This article provides an overview of how implementing a formalized transition of care process can lead to a safer Environment of Care.

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Journal of Nursing Education and Practice

ISSN 1925-4040 (Print)   ISSN 1925-4059 (Online)

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