The
term “transition care” discusses about the movement patients between health
care system level and settings as patient’s condition requires change during
the development of an acute or chronic disease. (Naylor, 2008) For instance, a
patient with renal disease during an acute exacerbation of disease, a patient will
have admitted to a hospital to receive care from physician with specialties and
nursing team during stay hospital. Thereafter, the patient will discharge and
might return home. Based on patient’s condition he or she might receive care from
a nurse in home setting. Each of these changes from hospital to home is defined
as a care transition for continuity of health care. Transition of care is
important because more and more health care is moving from inpatient setting to
patient’s home due to costs of hospitalization is very expensive. In the
transitional care, nurses work with patients and entire healthcare team to make
sure that patient after discharge, patient receives continuity of care and
stability during their transition from hospital to home.  

            Transitional care is comforting
source of support for patients after discharge. Nurses are able to track all
problems that happens after transition from acute care to home. In addition,
nurses are able to focus on preventing the signs of readmission that resulting
in bad outcomes later. Nurses must keep tracking that patient is functional
physically and emotionally with in weeks after discharge. It is critical first
weeks coming out the hospital especially for older population because many
things can happen during this time. Therefore, it is important to make good
rapport with patient and knowing their concerns in order to reduce their stress
and address their concerns.

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Although, transitional care emphasizes on
continuity of care but there are barriers to achieve successful transition of
care. Poor communication would initiate unpleasant transition. For instance,
after discharge of the patient the health care professionals responsible for
carrying out discharge plan including physician, pharmacist, and nurse. They
are all disconnected from each other and no one is able to see the patient taking
medications filled, or patient was able to arrange a follow up appointment with
physician. Both lack or poor communication among health care professional
causes breakdown in the continuity of care. Also, incomplete transfer of
information and inadequate education of patient especially older population are
causing breakdown to this system. Language barrier, health literacy, and
cultural differences make barrier though this transition.

In order to achieve affective transition
care three criteria such patient-centered care, lower costs, and quality of
care should overcome. Each of these component is like an umbrella that
encompasses many other factors to lead effective transition care. As mentioned
earlier, poor communication affects the transition care, clinical communication
should improve between caregivers and receiver. Some of the benefits of the transition
care approach is the provider care plan. When patients are going home, they receive
information about the next appointment, the physicians contact numbers. This
simple information can display support and continuity of care before their departure
from hospital. This system also, enhance the team work among health professionals
because the whole team should preset to plan discharge that is more meaningful and
beneficial to the patient. In addition, when crisis has come up instead everyone
trying to scramble and figure out best solution, health professionals are all in
same team from the beginning, so they can participate the problems and quickly and
efficiently counter unexpected problems.