News From the National Case Management Network of Canada: A Systems-Level Approach to Safe and Effective Transitions
Joan Park MHSc, RN

Professional Case Management
June 2012 
Volume 17  Number 3
Pages 107 - 108
  PDF Version Available!

Poorly executed care transitions can result in medication errors, delays in care, and unavoidable readmissions. Accreditation Canada guidelines state that effective communication is a critical element in improving client safety, particularly with regard to transition points such as shift changes, end of service, and client movement to other health services or community-based providers (Accreditation Canada Required Organizational Practice-Information Transfer, 2010).The College of Family Physicians of Canada (2003) recommends that, to improve the continuity and coordination of patient care, appropriate communication should be maintained by hospitals and with family physicians in the community, including timely notification of their patients' hospital admissions, progress, and discharges. At St. Michael's Hospital in Toronto, Ontario, Canada, a number of initiatives address the gaps in care.The discharge process has commonly been referred to as a transition for the patient and the family (Weiss et al., 2007). Meleis' Transitions Theory details a "transition" as a process of passage from one life phase or status to another, during which changes in health status and ability create a period of vulnerability.The hospital discharge can be viewed as occurring in three stages: 1. Hospitalization-where discharge preparation occurs 2. The discharge 3. Postdischarge period-are patients able to cope with the demands of their environment?Was the right assistance put into place? The theory proposes that it is the nature of the transition, transition conditions, and therapeutic practices that determine whether the outcome is positive or negative for the patient (Meleis et al., 2000). A readiness for discharge assessment should be a part of discharge preparation for every patient (Weiss et al., 2007). Patients do not always feel ready for discharge and do not feel that they are adequately informed (Mistian et al., 1997). It was found that * a patient's perceptions of their readiness

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