Managing Care Transitions to the Community During a Pandemic

Abstract

This column discusses the establishment of a multidisciplinary model for care transition of COVID-19-positive patients from hospital to community. The pandemic has presented challenging issues for discharge transition. A tiered patient identification and clinical messaging referral system was developed. The use of the COVID-19 transition model provided support to patients and physicians during the 30-day discharge period and can serve as a model for emerging public health issues in the future.

Transitional Care in Times of COVID 19: Opportunities for e-Health Interventions

“…The pandemic has raised new and challenging questions in preparing for the safe transition to the community and halting the spread of COVID-19. Successful responses have emerged to address these challenges such as the development of a hierarchical system for identifying patients and forwarding clinical messages [11] and virtual care models have been widely accepted by patients and represent a key component for providing safe and timely health care during this pandemic [12]. In addition, students can be involved in conducting a health education session, as in a previous study in which trainees in their final semester and who used motivational interviews to help patients set goals in managing the disease.…”

Patients, Caregivers, and Healthcare Providers’ Experiences with COVID Care and Recovery across the Care Continuum: A Qualitative Study

“…For many, this has entailed a complex recovery comprised of interactions with multiple care providers in various care settings before returning to the community [2,3]. Navigating the care continuum is challenging for patients and families in the best of times and the COVID pandemic has undoubtedly overwhelmed the normal process of patient care management and increased the difficulty of care transitions and patient follow-up [4]. Although care transitions can be optimized through the support of family caregivers, they are often poorly engaged in the process [5].…”

“…One way that this challenge was met in the acute care setting was by accelerating the discharge timeline to move patients who had recovered from the most acute phase of their illness to post-acute care (e.g., inpatient rehabilitation) in order to free up beds for subsequent surges [8,9]. Although this strategy facilitated the transfer of the "least sick" patients [8], it precipitated a number of fears and anxieties amongst patients, families, and healthcare providers (HCPs), and enhanced the risk of patient complications, readmission, and disconnected care [4]. It was also unclear during the early days of the pandemic if rehabilitation hospitals were prepared for incoming COVID patients, with many experiencing shortages in both personnel and resources [10,11].…”

Quality of Care Transition for COVID-19 Patients in a University Hospital in Southern Brazil

“…It is common for COVID-19 victims to be discharged home with gaps in care transition, resulting in an increased incidence of complications, readmissions, and lack of care follow-up. Factors such as social determinants, health conditions, and housing conditions influence the ability of patients and families to follow up with post-hospitalization care ( 7 ) .…”

“…É comum pacientes vítimas da covid-19 receberem alta para a casa com lacunas na transição do cuidado, tendo como consequência o aumento da incidência de complicações, readmissões e a falta de seguimento no cuidado. Fatores como determinantes sociais, de saúde e condições de moradia influenciam na capacidade dos pacientes e famílias de seguirem acompanhamento extra-hospitalar após a internação ( 7 ) .…”