Transition of care in population health

Question 1

Define what constitutes care transitions

Answer 1

Transition of care occurs between all types of health care practices like pharmacy, physicians office, hospital, community support, and home health care
- Important for elderly patients, patients living alone, with care givers, complicated therapies, limited health literacy, patients without PCP

Question 2

Explain the importance of transition care management to
patients, caregivers, health care providers, health
systems, and insurers

Answer 2

Patients
- address an expectation of continuity of care especially within a health care system
Hospital
- reimbursments are tied specifically to readmission rates
- cost avoidance
Insurers
- cost avoidance
- improved outcomes

Question 3

Identify patients for whom transitions of care services are
especially important

Answer 3

• Important for elderly patients, patients living alone, with care givers, complicated therapies, limited health literacy, patients without PCP

Question 4

Identify key individuals who should be included of the
transitions process

Answer 4

patients, caregivers, physician/ advanced practice provider, nurse, social worker, case manager, and pharmacists

Question 5

Describe how pharmacy can impact transitions of care to
improve outcomes

Answer 5

• we can make sure to remain in contact with the patient during time of admission, throughout care, at time of discharge, and after discharge to make sure the patient is left with no questions of concerns about their medications/ treatment plans