Transitions in Care: A Key Role for RN Case Managers, Social Workers and Interdisciplinary Teams
Transitional planning is a process that ensures that patients have the best outcomes as they move through the continuum of care. It has become much more than just the movement of the patient out of the hospital. It is a “process” that starts at the point of admission and follows beyond discharge and through the continuum of care.
This program will review the concepts associated with the continuum of care in the new world of Accountable Care Organizations (ACOs), value-based purchasing and bundled payments. In addition, we will review how to engage other members of the interdisciplinary care team in the process of planning for the patient’s movement across the continuum including verbal and written hand-off communication. Transitional planning is no longer a destination but a process! Learn how to be certain that your processes address the complexities of the new healthcare environment. Ensure your alignment with your post-acute care providers.