Future Trends Health Care 2013 - Page 24

15. Transitional Care The actions of healthcare providers designed to ensure the coordination and continuity of health care during the movement/ transition of patients and patient’s medical information between health care practitioners and settings to reduce fragmentation of care by: Skills and Knowledge for Transitional Care: Acute to rehab to recovery Home health care Assess and treat multiple medical problems Home therapy Behavioral Management Hospice Clinical - Holistic Medicine Infection Prevention and Control Collaborative care Information Management Common language - of medicine Medical home technology Comprehensive information on high risk patients Medication Management Communication/Education/Collaboration National Patient Safety Goals Community Health Outpatient Continuum of care Palliative Care Cross discipline education Patient education Decreased re-hospitalization and institutionalization Polypharmacy and medication safety Decreased cost Disease processing More urgent care facilities Preventative medicine - Mammograms, Glucometer readings, Blood pressure readings Empowered patients Provision of Care, Treatment, and Services Environment of Care Reduced medication errors, interactions and side effects Ethics Genomics Rehab Glucometer readings/ Blood pressure Safety monitoring Short term acute care ©Copyright North Central Texas InterLink, Inc. All rights reserved 21