Case Management Society of America


Care Transitions: Remember the Basics


Care transitions, the movement of a patient between care settings, is one of the most discussed phrases in healthcare today. At one time, discharge planning was the focus of hospital efforts. “Discharge planning starts at admission” was the key phrase for many years. Over time, daily practice and research delved into the point of discharge and exposed the commonalities and risk of every point of transition in the healthcare continuum. The conversation evolved from one limited to preparing for a hospital discharge into an expansive conversation about safety, readmissions, communication and technology. Care transitions are discussed for patient movement between any two places of care and have spurred an industry.

A simple Google search for the phrase returned more than a million results. There are organizations, templates, standards, consultants, articles, coalitions, software, self-learning tools, conferences, models, measures, best practices and checklists of all varieties. The conversation is so expansive, it is hard to know where to start, never mind how to pick what is most applicable to the transition in question. Numerous supportive tools guide clinicians of all varieties to use standard communication methods and mechanisms, identify key points of risk and useful follow up to catch problems early. In all this effort, attention and research, one thing seems to have been overlooked: the most basic aspects of “How do I take care of my loved one?”

One of the most common and most unrecognized experiences of nurses and other clinicians in the home, whether home healthcare or hospice, is the always-surprising continuum of how different people do the same thing. How a caregiver assists his or her loved one to get out of a chair for instance. Trained clinicians will help the person scoot the edge of the seat, check for sturdy footwear, make sure his or her feet are flat on the floor and shoulder width apart, look for armrests to push up from, move a walker or cane into position, place one foot in a T position to the lead foot, bend our own knees, use a gait belt placed low and snug but not tight around the person’s waist or perhaps put our hands under the armpits and instruct the person to hold on to our forearms. We have been taught and practiced these steps, intentionally, over time and with guidance. This is not what non-professional caregivers do.

Non-professional caregivers commonly do a lot of tugging and pulling. There are false starts, angry words and injuries to both parties. People grab hands and pull, yell, push from behind; occasionally, the chair may even be tipped forward to move the person out of it. The neck of the caregiver is frequently used as a bar to pull up on when trying to stand. Shoelaces are left dangling. Socks on slippery floors are common. Tugging on the waistline of pants, pulling shirts and just full-on deadlifts occur daily. The stress from these moments is palpable. Both parties are in jeopardy. Fear is common. Both parties fear sustaining an injury. Shared anxiety expressed as anger only makes a risky situation more dangerous.

Adult diapers are another unspoken basic. How do I secure an adult diaper? Which way is the front? Can it be changed if they are lying down? What if they only stand while I hold them, how do I put on a new one? Are they different for men versus women? There are books, videos, helpful grandparents, childbirth classes and labor and delivery nurses to guide new parents to change the diapers of an infant. How do new caregivers of impaired adults learn this skill? Commercials teach us to transition from diapers to underwear like garments for toddlers. Packages tell us what size of either product to buy for children. There is not an equal marketing initiative for adults with the same needs. Cleaning the peri area from front to back, retracting the foreskin, cleaning in skin folds and using non-irritating products are all points clinicians are taught. Over time, these skills become so basic they are automatic. But first, there was teaching and learning.

Nurses in homes hear a wide variety of questions about these basic, almost invisible skills. How can the sheets get changed if my loved one doesn’t get out of the bed? How do I wash my loved one if she can’t take a shower? Can I shave his face? What about the dentures? How do I take them out? Do I have to take them out? How does this hearing aid go in? Is it on? How can she brush her teeth if she can’t get to the bathroom? These are just a few of the more common questions nurses and other professionals providing care in the home hear or observe. Far too often, non-professional caregivers don’t ask, they just do.

Sometimes the innovative ways people invent to “just do” are brilliant, such as using kids’ toys to expand a person’s reach. Often, they are dangerous, like bending over a bed and trying to lift a person who cannot help or feeding someone who is lying down. Sometimes, lack of knowing leads to not doing, which is also a dangerous choice. When caregivers don’t know how to change the sheets with their loved one in the bed, sometimes they don’t get changed even when they are soiled. Well intentioned, devoted caregivers without knowledge or skill can inadvertently leave a person in soiled clothes or sheets, leading to skin breakdown and other problems. A patient may attempt to avoid urinating to reduce stress in the home, leading to dehydration and further complications. This lack of ability and know-how commonly comes with feelings of shame and embarrassment for both the person and the caregiver, only worsening the situation.

These types of basic care are easy to forget and overlook in a facility setting. Institutions — hospitals, rehabilitation facilities and nursing homes — provide this care consistently, typically with minimal thought. Planning for care transitions typically includes conversations about when to change settings of care, where to go and how to get there. Follow-up visits, medication management, durable medical equipment and communication plans are critical to a successful transition, but it is not an exhaustive list.

Prior to the research defining the link between medication management and readmissions, medication education was often taken for granted. Facility-based nurses often trusted that caregivers already knew about using the medications correctly. Research demonstrated a significant gap and highlighted the need for careful, planned education for patients and caregivers prior to discharge. It challenged the assumptions professionals made about what people already knew and pushed for active confirmation of critical knowledge. These needs have been built into care transition tools to help remind professionals to illuminate and focus on issues of safety.

When home is the next setting, nurses are growing increasingly attentive to including the caregiver as an equal partner in education. Case managers regularly assess caregivers to evaluate their ability to perform the skills required to care for the patient at home. Beyond the physical capacity, case managers must assess if the caregiver has the knowledge to perform the skills safely and ensure the answer is yes prior to the discharge.

This focus has resulted in non-professional caregivers providing expert dressing changes and flawless intravenous medication administration in the home. These advanced skills are an obvious new challenge for non-professional caregivers and easily recognized as an educational need. Case managers now need to apply this process to skills which are not as obvious. The need to ensure advanced skills are developed in caregivers doesn’t negate the importance of the basic skills. Without the ability to ensure core activities of daily living are performed safely, the more advanced skills can be negated. Care transition planning frequently fails to focus on these basic components of personal care.

A referral to home healthcare is an important step to helping people recover. Best practice in home healthcare and hospice is to make a visit to the patient’s home within a day of discharge. But for new caregivers or people with very different capacity than prior to the facility stay, even a day can be too long. When even simple activities of daily living like standing or eating are difficult, being home can be terrifying. As data continues to reveal when patients have readmissions and why, new strategies will be defined to continue to improve patient safety and improve the ability to stay home. Even before this data exists, though, nurses can apply what is known and invest greater resources into the basics of personal care.

Literature about preparing new parents to take care of infants demonstrates the importance of caregiver confidence. When caregivers are confident and prepared for the job ahead of them, it is reasonable that the job will be more successful. If worry, fear and anxiety surround skills as basic as standing up or cleaning up after urinating, energy and focus are distracted from more complex skills, like medication safety. Nursing school demonstrates the need to start with the hands-on skills before progressing. Each nursing student starts by mastering personal care before tackling medication administration. The same progression is typically forgotten for hospitalized patients. The focus on more complex aspects of care cannot be sacrificed, but time for the basics needs to be found.

Before the formal care transition pathway or care plan can start, facility nurses can start to support caregivers by partnering with them for personal care skills. The continuous nature of care in facility allows countless opportunities to teach, support and encourage caregivers to learn and practice these basic, critical skills. Home healthcare and hospice nurses do not have the same exposure or access. Opportunities to teach and coach are limited to several times a week or perhaps daily. If the principles of patient education, including teach back and demonstration, are applied to the activities of daily living, care transitions can only grow safer and caregivers more confident.

Case managers can include assessment of the ability to perform activities of daily living as an active part of readiness for discharge assessments. Strategies and mechanisms used to prepare caregivers for advanced care needs can be utilized to ensure the basic skills are mastered as well. Promoting active engagement between caregivers and hospital or facility staff during caregiving activities forms a natural teachable moment. When true partnership is achieved, learning can be robust. Many caregivers have invaluable tips and inventive solutions to share when we take the time to learn what they know and support healthy solutions to daily challenges.

For resources regarding the topics discussed in this article, please visit and  ■

Danielle Pierotti, RN, PhD, CENP, is the vice president, Quality and Research, with ElevatingHOME and the Visiting Nurse Associations of America (VNAA). She leads the development and integration of evidence into all aspects of home-based care in support of the national quality agenda. Dr. Pierotti’s clinical practice included adult medical-surgical, oncology, hospice and leadership in hospitals, clinics and homes. She pioneered a new role specializing in nursing quality, leading and developing initiatives across a community hospital system, including both in and outpatient care. As chief nurse for a rural hospice provider with a 25,000-square-mile service area, she translated the Magnet Model for clinical excellence into the interdisciplinary environment of home-based care. Dr. Pierotti’s primary research interest is patient outcomes and the intersection between practitioner knowledge, practice and outcome. As an educator, author, presenter and researcher, Dr. Pierotti strives to actively promote and develop the practice of nursing as a central strategy to maximize human health through the application of knowledge and use of measurement.

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