A comprehensive process designed to ensure a smooth transition of care for patients leaving a healthcare facility, such as a hospital or rehabilitation center, to their next level of care or home environment.
The provision of coordinated and continuous care during the transition from one healthcare setting to another, aimed at preventing complications, promoting recovery, and optimizing health outcomes.
The deliberate organization and integration of healthcare services to facilitate the appropriate delivery of care across multiple providers, settings, and time points, particularly during transitions such as discharge.
The process of supporting and representing the rights, preferences, and needs of patients, ensuring they receive optimal care and services throughout their healthcare journey, including during discharge planning.
The systematic process of comparing a patient’s medication orders to all of the medications the patient has been taking to avoid medication errors during transitions of care, such as hospital discharge.
The provision of ongoing support and monitoring to patients after they leave a healthcare facility, including scheduled appointments, telephone calls, or home visits, to prevent readmissions and ensure continuity of care.
The process of discussing and documenting an individual’s preferences for future medical care and treatment, including end-of-life decisions, to guide healthcare providers and family members in decision-making during critical situations.
Written or verbal guidance provided to patients and their caregivers upon discharge, detailing important information such as medication regimen, follow-up appointments, activity restrictions, and signs of complications.
Healthcare services provided in the patient’s home by licensed professionals, such as nurses, therapists, and aides, to support recovery, manage chronic conditions, and promote independence following discharge from a hospital or skilled nursing facility.
A healthcare professional, often a nurse or social worker, who assists patients and their families in navigating the complexities of the healthcare system during transitions of care, offering education, support, and resources to promote successful outcomes post-discharge.