Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Care Transition

• Assessment of client’s needs to prepare for transition is an important and it should begin early and it is an ongoing process.
• Continuity of care on transition is supported by early transition planning --well before discharge, and must include the client/family/caregivers in the planning.
• A comprehensive assessment of care needs can prevent readmissions and unfavourable client outcomes.
• Medication Reconciliation is an important component of care transitions for client safety. A standardized and structure approach is the best way to obtain Best Possible Medication History.
• Identifying the stage of psychological readiness of the client is as important as the physical readiness. This is required for effective planning and implementing strategies to help the client, their family and caregivers progress and be psychologically prepared for care transition.
• Understanding the client’s willingness to learn and identifying factors such as health literacy and language proficiency that would be a barrier to learning must be assessed to plan strategies to achieve effective education on aspects self-care.
• It is important not to overwhelm the client with too much information - Each stage of care may bring on need for new information.
• Education on aspects of self-care is only meaningful to individuals if it reflects their needs!
• Use of open ended questions and use of the teach-back method supports the education and conversation.
• The strongest predictor of client’s readiness is the quality of teaching, it should be part of daily nursing routines and followed up with written material
• Coaching the client to be able to take care of themselves to the extent that they are able is critical for safe care transitions. Nurses act as transition coaches and provide education/teaching on: the client’s condition, warning signs to watch out for and how to respond to them, when to seek help and medication, diet and treatment regimens
• Planning also includes knowing and understanding what is needed at both the sending/receiving settings or by the health-care providers.
• Reviewing the transitions plan status should be part of routine daily care to ensure progress is being made, identification of new needs so that the client is ready.
• Nurses should monitor and evaluate the client’s preparedness by watching for: gaps in care, need to reinforce or clarify self management processes, the need by the client for additional education or resources and their intent to follow up on post transition appointments with primary care providers or specialists.
• Nurses can improve the communication and relationships between interprofessional team members and the client during the transition planning process and be active participants in the decision making processes during team meetings to organize and plan the care transition