Case Management

Case management Q&A

Case Management Weekly, September 26, 2012

Q. How do home care and transitional care differ? 

A. Transitional care emphasizes empowering patients for self management, not providing care. This can be difficult for nurses assuming the transitional care role. Nurses are accustomed to doing things for people; they want to help. It is a shift in paradigm to help by not doing something. Nurse may need a lot of practice to step back and ask patients to demonstrate how they would do something rather than just doing it for them. 

The relationship with the patient begins in the hospital. So the transition coach or transitional nurse is well acquainted with the hospital course. Transition staff is part of the hospital team, so they have a close working relationship with the physicians, nurses, and ancillary care staff. Transition staff act as liaison between the hospital and home care nurse. The latter often have questions about a patient’s hospitalization or why a discharge includes certain orders. Transition staff can clear up any confusion. 

This week’s Q&A is adapted from Reducing Readmissions: A Blueprint for Improving Care Transitions published by HCPro, Inc.

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