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Re-energizing Standards of Practice in Transitions of Care

The COVID-19 pandemic has tested our ability to coordinate care and ensure that patients safely and effectively transition between care setting. During this time, many of us quickly adjusted key processes that, under normal circumstances, would have taken years to modify. Some of the changes made were a shift to telehealth care coordination visits by health care providers, quickly changing and preparing the ability to work remotely and conduct telephonic or telecommunication platforms to collaborate with the transition team, family members and patients, and the increase of completing advance care planning, especially for patients recovering, diagnosed or at high risk for COVID-19.

Organizations need to review 2020 and identify how transitions of care was managed. What worked well? What needs to be improved? Or what needs to be “kicked to the curb”. Re-Energizing Established Standards of Practice in Transitions of Care Many organizations have reviewed and improved their transitions in care management over the years and have established and have even implemented evidence- based processes as provided in the CHN Senior Care in Motion Transition Tool Kit. Now is the time to review, revise and re-educate the standards of transition within your organization. The following, in accordance to the Tool Kit and transitions in care standards of practice would include:

  • Pre- Admission Determination: Gathering Inquiry Information to include all pertinent information of the potential resident’s Needs and Risks to aid in admission decisions.

  • Admission Process: First 48, Ensuring a warm welcome and establishing a base line plan of care that is resident focused and addresses all the Needs & Risks to aid in chronic disease management and preventing adverse occurrences that can lead to rehospitalization.

  • Transfer Process: Reviewing existing Transfer Process to ensure that SBAR and Transfer forms include all pertinent resident information, including COVID history, vaccination and chronic disease risks that can impact recovery.

  • Discharge Process: Review existing Discharge Process to ensure that effective hand- off is provided in writing and verbally to next level of care provider to ensure continuity of care plan and management of chronic disease condition and risks that may lead to a need to return to the SNF due to change of condition.

  • Culture of Awareness: Ensuring that ALL residents’ needs, and risks are communicated to ALL care associates enabling them to be aware of and communicate signs/ symptoms of change in condition and the need to implement interventions to prevent adverse events.

If further assistance is needed to provide education, review, and revise existing systems or receive a copy of the CHN Senior Care in Motion Transition Tool Kit do not hesitate to contact Diane Kubala, VP Care Transitions & Emergency Preparedness at


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