Moving a patient from one facility to another can be dangerous. In fact, there is an increased risk that adverse events can happen due to miscommunications within this process. 

Every time someone is discharged from a hospital and transferred to another care facility, it is a complex process. In order to improve transitional care, you need to improve the communication between all parties involved. That way, any risks of incorrect diagnoses, improper treatments, and wrong prescriptions are avoided.

What Is Transitional Care?

Transitional care is for patients who are transferring from a hospital to another facility or their homes for further recovery. It is especially important for the elderly who have multiple chronic conditions and complex regimens. If a miscommunication occurs, such as a regimen being missed or some medication not taken, it could lead to disaster. 

How To Improve Communication

Improving communication is an important step to ensure no one gets lost in the transition. Any miscommunication could be disastrous—possibly even fatal. 

Here are some ways to improve communication:

Educate All Parties About Medication

The first thing you should do to improve communication is to educate the patient, family, and caregivers of the patient about their medications. This means teaching caregivers about what medication they need to take and when, and in what quantities each serving must compose of. It also means explaining each medication’s purpose and potential side effects! Aside from that, you should make sure that all parties understand how to get the medication and where.

Plan The Transition

Firstly, assess the home environment and patient needs after discharge. Then, educate the patient and the caregivers on self-care management and expectations. Make sure to explain this to them in terms they can understand. 

Further Educate Patient And Family

Explain to the family and patient what exactly a worsening condition looks like. Identify and red flags they need to look out for and what they can do about it. Make sure they understand by having patients explain it back to you.

Ensure Information Is Transferred Properly

Make sure critical patient information is transferred within 24 hours. Try to use specifically designed tools, such as a transfer tool, transition record, or transition summary. Have people specifically assigned to be care coordinators who will facilitate provider-patient communication.

Provide Follow-Up Care

Ensure that any primary care or specialist appointments have been finalized. Make sure to schedule any necessary testing before you discharge the patient. Provide them access to a 24/7 helpline. Have an RN call up the patient immediately post-discharge to monitor the patient’s condition. 

Keep in frequent contact so that you are better able to detect subtle changes in patients’ conditions.

Stay Engaged With Your Patient

Have a personal physician so you can have an ongoing relationship with the patient. Coach your patient on self-care—write down instructions when giving them to the patient and family. Make sure all providers are able to communicate with each other and you about patient status and progress. 


Now that you know the above tips to ensure better transitions, you will be much less likely to have an accident occur. Don’t forget to provide follow-up care and stay engaged with the patient. Remember to always be available for any questions that the patient or their caregivers may have!

Are you looking to make transitional management care much easier for your patients? Medistics Health has got exactly what you need! We are here to simplify the experience—with our help, your patients will surely get the best help they could possibly receive when transitioning care. Connect with us today to find out more!

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