12 Lessons on Caregiver Engagement in Care Transitions

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A transitional care program succeeded in educating and involving family caregivers in chronically ill patients' care, according to a United Hospital Fund report.

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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