Sooner or later aging parents get swept into the complex currents of transitional healthcare. It may be a simple back and forth between the primary care provider and one or more specialist, or it could be a major health setback that sends them into a crisis cycle of hospitalization, rehabilitation care, and finally back home. Big or small, acute or chronic, all of these transitional events require multiple “handoffs” between medical professionals, hospitals, skilled nursing homes, and caregivers, and there’s the rub.
The stories of what can and does go wrong with these transitions are legendary, maddening, and in most cases preventable. The sad truth is that older adults many times wind up back home with defective marching orders regarding their medications, recovery plan, and follow up care. Given the frequency and severity of the problems surrounding transitional events, what can make this better?
The good news is that Dr. Eric Coleman from the University of Colorado Health Science Center has a compelling answer: The Care Transition Program. His program is based on what he calls the Four Pillars?, an integrated transition management system that prevents medication problems, insures information continuity between handoffs, clear, follow up orders, and a protocol that identifies red flags that could crash the process.
It is a practical, brilliant solution that is gaining a growing population of followers across the country.
One key element critical to the program’s success is a Transition Coach?. This is usually a geriatric nurse practitioner that provides in-hospital coaching to both patients and their caregivers to help both parties prepare for the transition. As important, the Transition Coach? does follow up visits to skilled nursing facilities or the patient’s home to insure continuity across the transition.
To learn more about Dr. Coleman’s remarkable program and download a copy of his “Transition Survival Skills,” click here: http://www.caretransitions.org/transitionskills.asp