CONCEPTS OF TRANSITION CARE AND CASE MANAGEMENT

[Audio] CONCEPTS OF TRANSITION CARE AND CASE MANAGEMENT HS3225/HS5342 TRANSITION AND PALLIATIVE CARE Good day everyone! Let's talk about Concepts of transition care an dcase management today. Let's go through the learning objectives first..

[Audio] LEARNING OBJECTIVES Explain the concept of transition care in Singapore’s healthcare system Examine case management for clients with chronic disease Explain the direct impact of case/community management on the healthcare system This lecture aims to give an overview of transition care pertaining to Singapore health care system. The first learning objective for this lecture to explain the concept of transitional care in singapore's health care system. At the end of the lecture, you should be able to examine case management for clients with chronic disease and the impact of case Community management of the health care system. The last two objectives will be revisited again in future lectures, so I will not be going into the details..

[Audio] DEFINITION Care Transition Transitional Care Actions ensuring Coordination and Continuity of care during care transition Movement from Health Care setting to another/home Now, is care transition the same as Transitional care? Transitional care is a management model used in case management Care Transition is defined as the movement from healthcare setting to another setting or home. what does it mean? let's say a patient is admitted to an orthopedic ward for fracture femur and had an operation done to fix the fracture. Post operatively, he needs long term rehabilitation before he can be discharged home. The doctor transfers him to a community hospital for rehabilitation before home…….That is care transition. Whereas transitional care is defined as actions, ensuring good coordination and continuity of care during the transition. So how do we ensure a good transitional care of this patient ? This will involve the role of a care manager to ensure that the patient has a discharge summary from the acute hospital, effective communication and meticulous hand over to the staff at the community hospital to ensure a smooth coordination and continuity of care for the patient ..

[Audio] TRANSITIONAL CARE MODEL Designed to prevent health complications and rehospitalizations of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up. There are multiple transitional care models designed to prevent health complications especially for the elderly who are chronically ill. The models involve comprehensive discharge planning and home followup..

[Audio] ERIC COLEMAN: ‘THE FOUR PILLARS OF CARE TRANSITIONS’ Medication self-management The Personal Health Record Timely primary care/specialty care follow up Knowledge of red flags that indicate a worsening in their condition and how to respond The most common model used is the Eric coleman's the four pillars of care transitions that includes medication self management, patient's health record, timely follow up care and recognizing red flags of their disease...

[Audio] THE CARE TRANSITIONS MODEL Focuses on patients at high risk for complications or rehospitalization. Prior to discharge from the hospital, a trained nurse visits the patient to begin the process of a successful transition to self-management at home. For patients released to a skilled nursing facility, the nurse makes a second visit prior to discharge home. At the home visit, the nurse reviews medication orders, educates about warning signs (“red flags”) of a worsening condition and reviews the Personal Health Record. Provides support in communicating with care providers Three follow-up phone calls are made : two days later, a week after that, and then two weeks later. This is an example, how the care model works: Prior to discharge from the hospital, a trained nurse visits the patient to begin the process of a successful transition to self-management at home. For patients released to a skilled nursing facility, the nurse makes a second visit prior to discharge home. At the home visit, the nurse reviews medication orders, educates about warning signs ("red flags") of a worsening condition and reviews the Personal Health Record. Provides support in communicating with care providers Three follow-up phone calls are made : two days later, a week after that, and then two weeks later..

[Audio] CHRONIC DISEASE CASE MANAGEMENT Case manager works with the multi-disciplinary team of care providers to define the agreed best practice for managing a specific population or disease while the patient receives care in and out of the hospital In chronic disease management, the case manager plays an important role. The Case manager works with the multi-disciplinary team of care providers to define the agreed best practice for managing a specific population or disease while the patient receives care in and out of the hospital The case manager is responsible for ensuring that these best practices are carried out in a timely manner for the patients with the use of clinical pathway.

[Audio] CONCEPTS OF CASE MANAGEMENT CARE TRANSITION Comprehensive care plan Well trained practitioners Patient’s treatment goal, preference and health status Patient & Family education Coordination among HCW Transition care in the concepts of case management involves a comprehensive care plan for patient, effective coordination between health care workers, managed by well trained practitioners, understanding patient's treatment goal preference and being a good resource person to support patient and family education..

[Audio] IMPORTANCE OF TRANSITIONAL CARE AND CASE MANAGEMENT Changing demographic & social profile Increasing acuity of illness Increasing usage of acute hospital beds Greater frailty of elderly patients Requiring longer period of care to recover Inadequate community support Escalating healthcare cost Fragmentation of services Repeated readmission The implementation of Transitional care and case management is implemented is essential to support the Singapore healthcare system as Singapore is an agein g society with many elderly with chronic diseases needing long term treatment. Being elderly, they are also susceptible to falls due to their frailty, thus requiring longer period of care. Transitional care aims to support and enhance community support for these elderly, manage escalating healthcare cost..

[Audio] IMPACT OF POOR TRANSITION OR CASE MANAGEMENT Wrong Treatment Delay in diagnosis Severe adverse events Patient complaints Returning to A&E Readmission to hospital Increased healthcare costs Death Ineffective transition care or poor case management can result in the wrong mode of treatment for the patient Poor communication between healthcare providers, inadequate discharge planning, and insufficient patient education are major contributing factors to readmissions Inadequate communication and coordination during transitions can lead to delays or missed treatments. This can result in the worsening of conditions, leading to further complications and hospitalizations The consequences of poor transitional care, such as readmissions and complications, contribute significantly to rising healthcare costs. This burden falls on patients, families, and healthcare systems.

[Audio] BENEFITS OF CASE MANAGEMENT Reduced length of hospitalisation Prevents multiple readmissions to hospitals Reduced unnecessary use of healthcare resources Increased patient’s satisfaction Reduced healthcare expenditures On the other side of the coin, effective case management plays a crucial role in ensuring patients receive the right care at the right time, leading to better health outcomes. This results in better control of chronic conditions, reduced hospital readmissions, and overall improved quality of life for patients Case managers act as patient advocates, providing support and guidance throughout the transition process. They help patients navigate complex healthcare systems, understand their treatment plans, and access necessary resources. Good case management can contribute to reduced healthcare costs by preventing unnecessary hospital readmissions, minimizing medication errors, and optimizing resource utilization. By coordinating care and ensuring timely interventions, case managers help avoid costly complications and emergency room visits. This efficient approach to care management ultimately leads to lower overall healthcare expenditures.

[Audio] References American Hospital Association (2020). Hospital and care systems of the future. Retrieved from https://www.aha.org/ahahret-guides/2011-09-16-hospitals-and-care-systems-future Cheah, J., & Wong, L.M. (2011). Integrate now, create health. Annals of the Academy of Medicine Singapore, 40(2) Geary, C.r., Schumacher, K.L. (2012). Care transition: integrating transition theory and complexity science concepts. Advances Nursing Science, 35(3), 236-248. Karakusevic, S. (2010). Designing an integrated health care system: What are the key features?. Journal of Integrated Care, 18 (4), 36-42. Ministry of Health, (2019), Community Health Assist Scheme. Retrieved from https://www.moh.gov.sg/cost-financing/healthcare-schemes-subsidies/community-health-assist- scheme Naylor, M & Keating, S.A. (2008). Transitional Care: Moving patients from one care setting to another. American Journal of Nursing. Vol 108(9) Supplement, September 2008, p 58–63. https://doi: 10.1097/01.NAJ.0000336420.34946.3a.