Best Practices for Managing Resident Transitions Between Care Levels
Introduction:
Transitions between care levels are a critical part of providing high-quality, person-centered care in an Adult Family Home (AFH). Whether a resident is moving from independent living to assisted care, from an AFH to a skilled nursing facility, or even from hospital care back to the AFH, these transitions require careful planning and coordination to ensure safety, continuity, and minimal stress for the resident and their family.
Poorly managed transitions can result in medication errors, unnecessary hospital readmissions, confusion among caregivers, and distress for residents and families. By implementing structured transition protocols, clear communication, and proactive planning, AFH providers can make care transitions smoother and more successful.
In this article, we explore best practices for managing resident transitions between different levels of care while maintaining safety, dignity, and emotional well-being.
1. Assessing Resident Needs Before Transitioning
The Challenge:
Each resident has unique medical, emotional, and social needs that must be carefully evaluated before transitioning to a different level of care.
Best Practices:
Conduct a Comprehensive Assessment:
Review the resident’s current health condition, cognitive function, mobility, medication needs, and emotional state.
Identify any new medical conditions that may require additional services.
Involve a Multidisciplinary Team: Consult with physicians, nurses, caregivers, therapists, and family members to determine the best care setting for the resident.
Evaluate the New Care Setting: If transitioning to a nursing home, hospice, or hospital, ensure the facility is equipped to meet the resident’s needs.
Taking time to assess and plan before transitioning prevents gaps in care and ensures the new environment is a good fit for the resident.
2. Creating a Detailed Transition Plan
The Challenge:
Without a structured transition plan, key details can get overlooked, leading to confusion, delays, or resident distress.
Best Practices:
Develop a Step-by-Step Transition Checklist: Include tasks such as medication reconciliation, medical history transfer, caregiver instructions, and family communication.
Set a Clear Timeline for the Move: Establish who is responsible for each step in the transition (e.g., transporting the resident, sending medical records, notifying care teams).
Prepare a Resident-Centered Care Plan: Ensure the new care team understands the resident’s routines, preferences, dietary restrictions, and social needs.
A well-organized transition plan minimizes disruptions and ensures the continuity of care between facilities or care levels.
3. Communicating Clearly with Residents and Families
The Challenge:
Transitions can be emotionally challenging for residents and their families, especially when moving to a higher level of care or hospice.
Best Practices:
Keep Residents and Families Informed:
Provide honest and compassionate communication about why the transition is necessary and how it will benefit the resident.
Allow families to ask questions and express concerns.
Offer Emotional Support: Moving to a different level of care can be overwhelming and emotional for residents. Offer counseling, peer support, or religious/spiritual guidance if needed.
Provide Written Documentation: Give families a summary of the transition plan, contact information for the new care team, and details about next steps.
Transparent and empathetic communication reassures families and helps residents adjust more comfortably to their new care environment.
4. Coordinating Medical and Medication Transfers
The Challenge:
Miscommunication about medical history, medications, or ongoing treatments can lead to serious health risks.
Best Practices:
Ensure Medication Reconciliation:
Verify current prescriptions, dosages, and administration schedules before the transition.
Coordinate with pharmacists and doctors to avoid medication errors.
Transfer Complete Medical Records:
Ensure the receiving facility or care team has access to:
Recent medical history
List of medications and allergies
Previous hospitalizations or surgeries
Any special care instructions
Schedule Follow-Up Appointments: Arrange for post-transition check-ups to ensure the resident is adjusting well to their new care setting.
Proper medical coordination prevents complications and ensures continuity of care during transitions.
5. Supporting Emotional Well-Being During Transitions
The Challenge:
Transitions can lead to anxiety, depression, or resistance, especially for residents who feel uncertain about leaving familiar surroundings.
Best Practices:
Create a Personalized Transition Experience: Allow residents to bring personal belongings, familiar items, or pictures to help them feel more comfortable in the new environment.
Encourage Resident Participation in Decisions: Give residents some control over their transition by involving them in care plan discussions and move preparation.
Provide Peer Support and Social Engagement:
If possible, introduce residents to new caregivers, roommates, or social groups in the new setting.
Maintain social connections with old friends and family members through visits or video calls.
Helping residents emotionally adjust makes transitions less stressful and more positive.
6. Conducting Follow-Ups After the Transition
The Challenge:
Once a resident transitions to a higher or lower level of care, AFH providers may lose track of their well-being.
Best Practices:
Check In With Residents and Families: Within the first week after transition, follow up to ensure the resident is comfortable and receiving proper care.
Address Any Immediate Concerns: If families report issues with medication, social adjustments, or medical care, work with the new care team to resolve them quickly.
Maintain a Relationship with Former Residents: If a resident moves to hospice or a skilled nursing facility, consider occasional check-ins or visits to provide emotional support.
Post-transition follow-ups ensure residents settle in well and receive the best possible care.
Conclusion:
Managing resident transitions between care levels requires careful planning, communication, and coordination to ensure safety, comfort, and continuity of care. Poorly managed transitions can lead to medical errors, emotional distress, and confusion, but by following best practices, AFH providers can make these transitions smooth and positive experiences.
To improve care transitions, AFH providers should:
✅ Conduct thorough assessments before transitioning residents.
✅ Develop a structured transition plan to minimize disruptions.
✅ Communicate openly with residents and families about the move.
✅ Ensure all medical records and medications are properly transferred.
✅ Support residents emotionally to help them adjust.
✅ Follow up after transitions to monitor resident well-being.
By implementing these best practices, AFH providers can enhance care quality, reduce stress, and ensure residents receive the appropriate level of support throughout their care journey.
References:
Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices https://www.ncbi.nlm.nih.gov/books/NBK555516/
Transitional Care Strategies From Hospital to Home https://pmc.ncbi.nlm.nih.gov/articles/PMC4272352/
Best Practice Transitional Care: Updates for Case Managers https://ccmcertification.org/sites/ccmc/files/CCMC%20Webinar%202%20Transitional%20Care_Slides_FINAL.pdf
ACP Offers Best Practices to Improve Care Transitions Between Settings https://www.acponline.org/advocacy/acp-advocate/archive/may-5-2023/acp-offers-best-practices-to-improve-care-transitions-between-settings
Transitional Care Management: Practical Processes for Your Practice https://www.aafp.org/pubs/fpm/issues/2019/0500/p27.html
Inpatient Transitions of Care: Challenges and Safety Practices https://psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
Best practices for safe (and successful) care transitions https://www.wolterskluwer.com/en/expert-insights/best-practices-for-safe-and-successful-care-transitions
Beyond the Discharge: Principles of Effective Care Transitions Between Settings https://www.acponline.org/sites/default/files/acp-policy-library/policies/beyond_the_discharge_principles_of_effective_care_transitions_between_settings_2023.pdf
Care Transitions: Best Practices and Evidence-based Programs https://chrt.org/wp-content/uploads/2019/10/CHRT-Care-Transitions-Best-Practices-and-Evidence-based-Programs-.pdf
