Coordinating and Managing Care during Transitions among Care Settings

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Overview of Teaching Strategy 

Older adults transitioning among care settings, such as from the hospital to home, especially those with multiple co-morbidities, are particularly vulnerable. The focus over the years has been to decrease health complications in older adults by increasing quality of care and communication during transitions to other care settings. This teaching strategy can be used to enhance student learning in beginning and/or advanced pre-licensure nursing courses. Students will examine common problems that cause poor transitions among care settings as well as discuss improvements that can be made to prevent poor outcomes for older adults during the transitioning process. 

Learning Objectives
Students will: 

• Assess and recognize older adult clients’ physical, emotional, and mental needs across care settings.
• Describe common problems associated with transitioning across care settings.
• Recognize and describe the impact of poor transitioning on older adults and the health care system.
• Understand the complexities of caring for older adults during transitions across care settings.
• Understand the importance of communicating and coordinating care with the interdisciplinary teams and family members.
• Understand the specific role of nurses when providing care before and during transitions. 

ACES Essential Nursing Actions 

• Assess Function and Expectations
• Coordinate and Manage Care
• Make Situational Decisions 

ACES Essential Knowledge Domains 

• Complexity of Care
• Vulnerability During Transitions 

NLN Education Competencies 

• Nursing Judgment
• Human Flourishing
• Spirit of Inquiry

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