PP106 – Transition to Home Care: Safe. Smooth. Sustainable.
In a changing healthcare landscape, the mission is to help patients achieve identified outcomes and optimal wellness. In order to provide holistic care in a value-based environment, we need to equip our patients with the tools and confidence to live their best independent life. The challenge is to achieve these outcomes in a cost-effective manner, with the resources that are available. In accordance with CMSA Standards of Practice, a comprehensive, holistic, and compassionate approach to care delivery is incorporated into the transition process (CMSA, 2010. Standards of Practice, p. 13).
Transitions of care are vulnerable points on the care continuum. A collaborative process among all service providers is imperative to maximize wellness and avoid rehospitalization. These transitions are client centered, goal oriented, and outcome based. Interventions such as the utilization of a standardized discharge checklist ensure home care services begin with all necessary resources in place. The case manager is integral to lead the multidisciplinary team.