Implementing and sustaining evidence-based practices in long-term care.

Care Transitions

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    This new guideline is designed to apply to all domains of nursing practice, including clinical, administration, and education, to assist nurses to become more comfortable, confident and competent when caring for clients undergoing care transitions. It is important that nurses, working in collaboration with the interprofessional team promote safe and effective care transitions. Care transitions depends on effective communication and coordination of client care by all interprofessional team members and with the client, their family and caregivers.

    Reference: Registered Nurses’ Association of Ontario (2014). Care Transitions. Toronto, ON, Canada: Author. http://rnao.ca/bpg/guidelines/care-transitions

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    The goal of the document is to act as a tool promoting standardization in transitional care practices for complex patients. The tool describes the benefits of using common practices.

    Reference: Health Quality Ontario. (nd) Adopting a Common Approach to Transitional Care Planning: Helping Health Links Improve Transitions and Coordination of Care. Retrieved from http://www.hqontario.ca/Portals/0/documents/qi/health-links/bp-improve-package-traditional-care-planning-en.pdf

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    This guide provides an interview process from introduction to closing that supports accurate and comprehensive medication information is communicated consistently across transitions of care.

    Reference: Institute for Safe Medication Practices (ISMP) Canada, In collaboration with SaferHealthcareNow (2012). Best Possible Medication History Interview Guide. Retrieved August 8,2016 from https://www.ismp-canada.org/download/MedRec/SHN_medcard_09_EN.pdf

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    The link takes you to the care plans and plan of care section 24 to 29 of the Ontario Regulation 79/10 made under the Long-Term Care Homes Act, 2007, Government of Ontario. Retrieved from https://www.ontario.ca/laws/regulation/r10079

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    The Health education fact sheet supports resident/family to understand that they are an important part of the health-care team. Speaking with members of the health-care team will help them get the information they need to understand any changes in their health and what it means for the situation.

    Reference: Registered Nurses’ Association of Ontario (2014). Care Transitions. Toronto, ON, Canada: Author. http://rnao.ca/bpg/guidelines/care-transitions

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    The Care Transitions Education Project (CTEP) delivers educational models to increase nurses’, nursing students and cross continuum team members’ knowledge and skills for executing effective patient care transitions and lets nurses practice them during interactive learning activities and experiences. The modules require the learner to sign in.

    Reference: Care Transitions Education Project. (nd). Retrieved from http://www.caretransitionseducation.org/

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    This resource (policy directive) from the New South Wales, Ministry of Health, Australia outlines a standard set of key principles for various types of clinical handover to assist with effective, concise and complete communication to support improved patient care. It also, includes is a tool that asks, “Does your process for clinical handover meet these standard key principles?” checklist. Covering leadership, handover-time/participants/place and process and valuing handover.

    Reference: Retrieved from: NSW Government Health retrieved on September 1, 2016 http://www0.health.nsw.gov.au/policies/pd/2009/pdf/PD2009_060.pdf

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    A quality improvement initiative looks at communication during shift report identifying 4 key themes as opportunities to improve upon. Improvement outcomes are shared in the article.

    Reference: Johnson C.,Carta, T., & Throndson, K. (2015) Canadian Nurse. Communicate with me: Information exchange between nurses. Retrieved from https://www.canadian-nurse.com/articles/issues/2015/march-2015/communicate-with-me-information-exchanges-between-nurses

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    This article looks at communication as being a key culprit in compromising patient safety in hand-over. Suggestions are given for strategies on how to approach hand-overs from shift to shift consistently, how to include patient and family along with potential barriers

    Reference: World Health Organization. (2007) Patient Safety Solutions. Communication during patient handovers. 1 (3). Retrieved from http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution3.pdf

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    Article focuses on key processes to include in shift.

    Reference: Wagner, A. (2015). Communication is key: The importance of effective hand-off reporting. Minority Nurse. Retrieved from http://minoritynurse.com/communication-is-key-the-importance-of-effective-hand-off-reporting/