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Coordinating and Managing Care during Transitions among Care Settings

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Getting Started 

This teaching strategy focuses on assessing expectations, coordinating and managing care, and making situational decisions with older adults. The strategy enhances students’ human flourishing, nursing judgment, and spirit of inquiry. 

1.  The following tools can be used in a variety of teaching/learning settings to enhance student learning and understanding of common problems associated with poor transitions, and improvements made to produce better outcomes for older adults during transitions: A) case studies and B) concept mapping. 

  • Case studies are useful in helping students better understand the challenges individuals and families face during end-of-life transitions. Case studies foster students’ critical thinking, by illustrating and contextualizing the complexities associated with end-of-life care. This approach is best suited for small group discussions or post-clinical debriefings/discussions.
  • Concept mapping facilitates students’ critical thinking related to the needs of older adults and their families during end of life decision making. Concept mapping, based on a clinical situations or case studies, stimulates student thinking and broadens their conceptualization of important end of life care needs, as well as allowing them to individualize those needs to a specific context, individual, and family situations. 

2.  The above tools should address common problems during transitioning across care settings, such as communication failure, poor care planning, poor continuity of care, increased medication errors, and inadequate patient and caregiver education. These tools should also further emphasize the essential and important role of the interdisciplinary team during discharge planning to other care settings. 

3.  Students should be encouraged to explore web sites such as the How to Try This and Innovative Care Models web sites for additional assessment tools and information.



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