Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Background Information

• The Excellent Care for All Act (Ministry of Health and Long Term Care, 2010) was introduced in Ontario, Canada. The Act mandates the use of evidence-based care and places particular emphasis on safe, effective care transitions.

• Care transitions occur within, between or across health-care settings and providers (Accreditation Canada, 2013, 2014).

• The Avoidable Hospitalization Advisory Panel report Enhancing the Continuum of Care (2010) identified improving care transitions require clinical and strategic partnerships and collaboration across organization and system boundaries.

• It said focusing on the following six elements would make for more effective transitions:
■ Client and caregiver education;
■ Client management at home;
■ Discharge planning;
■ Improved communication between clinicians, clients and across settings;
■ Medication reconciliation; and
■ Primary care: follow-up in the community.

• The Agency for Healthcare Research and Quality said coordinating care is essential for improving quality, effectiveness and efficiency and optimizing health outcomes (McDonald et al., 2007) and identified five elements required for effective coordination of care:
1. Involvement of a number of participants (the sending and receiving settings, health-care providers, clients, their families and caregivers, primary care physicians or specialists);
2. Participants interdependency to carry out different activities for care coordination;
3. Participants knowledge of roles and responsibilities in the coordination of care processes, and available resources;
4. Information exchange to manage the activities required for client care; and
5. Facilitation of appropriate delivery of health-care services as a common goal.

• The focus of this guideline, Care Transitions building the core competencies and concepts known to facilitate safe and effective care transitions.

• Care transitions in this guideline refers to: A set of actions designed to ensure the safe and effective coordination and continuity of care as clients experience a change in health status, care needs, health-care providers or location (within, between or across settings).

• This guideline provides evidence-based recommendations and is intended to assist nurses and other members of the interprofessional team to focus on evidence-based strategies in the context of the provider-client relationship before, during and after a care transition.

• It is important that nurses, in collaborating with their interprofessional team, know and work with clients, their families and caregivers to promote safe and effective care transitions using evidence based strategies.

• Effective care transitions depend on coordinated interprofessional careG that emphasizes ongoing communication among professionals and clients.

• A care transition consists of many interactions involving the communication of sensitive client information across multiple health-care providers and settings.

• Nurses are responsible for ensuring the communication of client information through any means (verbal, written, fax) meets regulatory requirements for privacy and security.

• Any exchange of client information at any time, whether internal or external, requires the nurse to adhere to the privacy, confidentiality and security regulations for the safe exchange of client information (CNO, 2009a).

• Nurses must also adhere to their organization’s policies and procedures and their professional standards on the management, flow and sharing of client information during a care transition.