Table 1

Description of transitional care interventions

AspectDischarge planningTreatmentsWarning signsPhysical acitivity
GoalsPrepare patient and family to manage care and recovery at home after discharge; continue to meet patient needs after discharge; ensure patient care is coordinated as patient returns home.Ensure patient and family know the treatments (eg, medications, wound care) to be used/applied at home; increase patient and family confidence and ability to use treatments correctly; improve patient health.Ensure patient and family know the warning signs that indicate worsening health conditions and what to do about them.Ensure patient and family understand the importance of physical activity during recovery; promote safe physical activity; prevent declines in patient ability to perform daily physical activities; promote patient return to usual daily activities.
Key components and activitiesAssess: patient and family needs related to managing care and recovery at home.
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Involve patient and family in: setting goals and planning care; identifying strategies to meet goals and home care needs.
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Prepare patient and family how to manage care and recovery at home after discharge (provide instructions and demonstrate skills).
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Address barriers to meeting goals.
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Organise and coordinate care with community providers.
Assess: patient self-care/family care management and learning needs; treatments prescribed but not used properly and underlying reasons.
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Involve patient and family  in: setting goals related to managing treatments after discharge and identifying strategies to meet goals.
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Teach patient and family about treatments to be continued at home, provide verbal and written instructions, demonstrate use or application of treatments.
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Resolve treatment discrepancies based on problem identified.
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Ensure that medication reconciliation has been performed on hospital admission and discharge and on returning home.
Assess: patient and family learning needs about potential warning signs specific to patient’s health conditions or surgical procedures.
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Teach patient and family about warning signs (eg, explain, demonstrate and/or provide written information on how to monitor and recognise them, what to do, when to get medical help, who to contact and when to go to the emergency room).
Assess: patient level of mobility and need for assistive devices; patient and family physical activity learning needs; barriers to physical activity.
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Involve patient and family in setting physical activity goals and identifying strategies to meet those goals.
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Teach patient and family about risks of bed rest, safe mobility, balancing rest with physical activity.
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Increase physical activity based on patient goals, physical abilities, activity tolerance, and health conditions.
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Address barriers to performing physical activity.
  • All interventions are initiated within 24 hours of hospital admission and continued daily throughout hospital stay. Discharge planning lays the foundation for the other three interventions and ends at hospital discharge. The other interventions continue after discharge for 1 month, with home visit and telephone follow-up, and their continued need is reassessed at 1 month postdischarge.