Nursing Plan: Creating a Smooth Patient Care Transition

Appeared in: Nurse Together

By: Karen Anne Wolf

Patient Care TransitionMrs. Lake, recently diagnosed with a serious heart problem, cardio-myopathy, was readmitted to the hospital with an unrelated GI illness.  Upon discharge to a rehabilitation center, the discharging staff failed to relay her cardiac diagnosis, medication, diet and activity.  This failure to communicate led to an episode of congestive heart failure, increased stress for the patient, and a longer course of recovery.

The hectic pace of nursing can make doing discharges seem to be a bothersome chore for nursing staff.  While many hospitals and long-term care settings may have a case manager or care coordinator, this does not relieve the nurses, as patient advocates, from their responsibility to work with the health care team to make sure that there is accurate information, along with the necessary resources, to support transitions. 

Where did the breakdown occur?   Being a patient is a stressful experience.  Patients face multiple transitions, or "hand-offs," in settings and caregivers.  Mrs. Lake went through at least three major transitions from the emergency departments, to the intensive care unit, and then on to the inpatient units, before being sent to a long term/rehab setting and finally home. 

This system breakdown lengthened Mrs. Lake's rehabilitation course and complicated her course of recovery.  Similar to many patients who are causalities of our health care system cracks, Mrs. Lake was made even more vulnerable by multiple chronic diseases.  The costs of such breakdown include slow recovery, and more often than not, add to the cost of health care, by adding to unplanned re-hospitalization.  A recent study of Medicare estimates that the cost of unplanned rehospitalizations in 2004 was $17.4 billion.

Communication and coordination can and should prevent such omissions at the time of transition.  This includes the following key components: 


  • Take time to educate the patient and their family members about the plan of care. If discharging the patient, provide a thorough, accurate plan.  Always assess the patient and family's understanding of the plan.  Don't forget the basics of nursing care, such as skin care, bowel and bladder care, and medication administration. 


  • Make sure that there is an accurate listing of diagnosis and any procedures that were done.


  • Always reconcile the patient's medications when "transitioning" the patient.  In addition, verify medication by name to match generic and/or brand names. This may mean faxing or phoning the medication list, and reviewing the list with the health care team members and family.


  • Be sure that other key aspects of the plan of care post transition are included for the next transition site: diet, exercise, treatments, therapies as well as equipment should be outlined in addition to medications.  


  • Be sure there is clarity about when, where and with whom follow-up care is scheduled.  This includes who should be called if the patient has a problem.

When it comes to discharge and coordination of care, the challenge for the future is to be proactive and creative to establish and expand systems of care that support our patients.  In a recent Hastings Center Report, nurse Mary Naylor and colleagues suggest that health care providers need to work with patients, family and other caregivers if they want to be successful.  "Be realistic" and develop care plans that patients can live with, and "make sure that there is professional support and follow-up through the critical period following hospitalization". 

The health systems care of the future need to assume responsibility for the care of our patient - vulnerable or not.  Communication and coordination of care will most likely include the technologies of electronic medical records and home care reminder calls; however, the technologies of care will only be as good as the effective and accurate care coordination of the full patient - family centered health care team.   


About the Author: Karen Anne Wolf PhD, RN, ANP-BC, FNA is currently associate professor at Samuel Merritt University in Oakland California. She has practiced as a community health nurse and adult nurse practitioner; and has served as a nurse educator for more than 25 years.  She has lectured and published widely on professional issues and nursing history, aging and health policy.   


Request more information

Vestibulum id ligula porta felis euismod semper. Nullam id dolor id nibh ultricies vehicula ut id elit. Sed posuere consectetur est at lobortis. Donec sed odio dui.