The report, “Engaging Family Caregivers as Partners in Transitions,” describes the results of the Transitions in Care-Quality Improvement Collaborative, a three-year initiative involving 45 teams of healthcare providers working to improve patient care transitions by engaging family caregivers in decision-making and educating them.
The report describes some of the lessons learned from the initiative:
Getting started
• Preparation is essential. Providers should map processes for care transitions to identify gaps.
• Both staff and family caregiver experience must be obtained and compared.
• Senior leadership must be engaged at the start.
Working with family caregivers
• Identify the appropriate family caregiver(s) in a systematic way, and enter this information into the electronic medical record.
• Talk to family caregivers about their own needs, capabilities and limitations.
• Use input from family caregivers to plan for discharge.
• Provide training and education, especially related to medication management and follow-up care, to family caregivers.
Making institutional change
• Improving transitions in care by involving family caregivers is a team effort that takes time, effort and senior leadership support.
• There must be clear responsibility and accountability within the team.
• Sustained quality improvement efforts require expertise in data collection and analysis.
• Partnerships between sending and receiving organizations need to be strengthened.
• Improving transitions requires an organizational culture that recognizes the value and needs of family caregivers and works with them as part of the care team.
More Articles on Care Transitions:
10 Actions to Improve Care Transitions Through Caregiver Involvement
9 Actions to Take During Post-Discharge Follow-Up Calls
Medication Reconciliation Program Cuts Hospital Readmissions 50%
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