The Four C’s in Community Transitional Care: Communication, Coordination, Continuity and Consistency

By:
Kirsten J Parkera,b RN, BN (Hons 1)
Prof Caleb Fergusona,b RN, BScN, MHlth, PhD, FACN, FESC, FCSANZ
Dr Julee McDonagha,b RN, BN, MN, PhD 
Prof Louise D Hickmana RN, BN, MPH, PhD

Affiliations:
a School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW.
b Centre for Chronic and Complex Care Research, Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW.

Transitional care is a commonly used term to define continuity of care as a person moves between healthcare settings or different levels of care. Simply, it refers to the continuity and coordination of care during this transfer (Australian Commission on Safety Quality in Health Care, 2017). These settings include the community, sub-acute, acute and aged care. For example, a patient’s care is transferred from the inpatient setting to the community after hospitalisation. While a transition in care can be a physical move, it also occurs between healthcare providers and clinicians. A transfer of care follows a change in the type of care required. Examples include when a person’s care needs change, when access to services changes or when the person’s location changes. Prioritising coordination and continuity of care during these transfers is essential for ensuring positive transitional care experiences.

Understanding the application of transitional care is important as it incorporates a broad range of services and healthcare environments. Clinicians in various roles commonly engage in transitional care practices and require a strong understanding of how to apply its principles. Research has established that ‘good’ transitional care can improve various health outcomes, including hospital readmission and medication errors. When care is communicated across the continuum, transitions are positive, and acute health service usage is reduced. A key element of transitional care is clinician and community-based health service utilisation (Manias, 2017). High-quality transitional care is especially important for vulnerable populations, specifically those with complex health conditions and comorbidity (Naylor & Keating, 2008). Therefore, understanding and supporting a person living with dementia to successfully and safely transition between healthcare settings is essential.

Transitional care in dementia
Transitions in care are inevitable for older adults living with dementia. We also know that older adults living with dementia commonly use health services more often than those without cognitive impairment. As a result of this cognitive impairment, transitions in care can often be daunting and complicated for this vulnerable population. This impairment can make it difficult for patients to understand and adapt to changes in their routine and environment, causing increases in confusion, agitation and uneasiness. Their ability to understand care information and instructions, or express concerns, is often challenging for this population. The person may be unable to communicate their specific care needs or preferences and may often rely on support from those around them. Therefore, it is important for all involved with the transition to consider any potential gaps in care for these populations to create the best chance at success.

• You might ask yourself, What does a ‘successful’ transition in care look like? It hinges on a combination of:
• Communication: Effective person-centred communication, handover and documentation between the patient, their family and the healthcare team is crucial for ensuring that everyone has a common understanding. At its core, transitional care is about considering future care needs and communicating them succinctly and successfully to those involved in the person’s care (Australian Commission on Safety and Quality in Health Care, 2017).
• Coordination: Coordination of transitional care also includes a comprehensive assessment of care needs with future care planning, ongoing education and support, and linkage of services throughout the transfer. As older adults living with dementia have challenges in vocalising their care needs, those around them in the transition need to advocate for their care needs.
• Continuity: Continuity of care is the need for seamless provision of ongoing, uninterrupted care over time, and this is an important tool in safe transitional care for this vulnerable population.
• Consistency: Consistency highlights the need for routine and familiarity especially for people living with dementia. Where possible transitions should prioritise the importance of providing reliable and predictable care. This includes consistent follow-ups, consistent application of care plans and consistent communication.

The critical role of the family and carer
Family and carers know their loved ones well and can help drive decision making and care provision through all aspects of care, especially when highlighting unmet needs. The role of family and/or carers in transitions in care is important as they are best placed to recognise changes in their loved one’s condition that might otherwise go unnoticed by health professionals unfamiliar to the person. Family or carers are a key stakeholder in supporting the success of the four Cs. They can help coordinate various aspects of care, from ensuring
medical follow-up to ongoing monitoring of conditions and symptoms. Furthermore, overseeing and managing medication reconciliation and administration play a vital role in keeping older adults living with dementia safe in the community. Simple activities like ensuring prescriptions are filled on time, and medications are taken when prescribed help to improve patient outcomes. Education, counselling and training of carers are also useful strategies to assist with the care of older adults living with dementia. Having educational information in different languages and accessible within different community settings are effective tools to help with the correct dissemination of information and training.

Family and carers are best placed to understand the medical needs and the patient’s emotional and psychological wellbeing. They play a vital role in decision-making practices and patient advocacy, especially for older adults with cognitive impairment. While they are of utmost importance when considering care in the community, it is important to consider their needs and foster an environment of support. As the needs of these individuals can be high, understanding the physical and mental load of caregiving is important, and clinicians should consider carer burden. This may lead to carer burnout and increased physical and emotional stress for those looking after older adults living with dementia, and clinicians are well-placed to recognise considerable strains on carers. Referring and assisting carers in accessing carer resources and services, such as ‘Carer Training’ are important tools to help reduce carer fatigue.

Transitional care in the community
The community setting is peppered with transitions in care. Examples of these transitions include the handover between staff working within community nursing services or a GP referring a patient to a physiotherapist. For example, a GP may ask a physiotherapist to review one of their patients for a mobility assessment after a decline in function. This assessment would then be communicated back to the GP, and a care plan would be created from these recommendations.

An awareness and understanding of the various facilitators and barriers to successful transitional care in the community is essential when working within these settings. Firstly, patient and carer engagement are important when optimising self-care practices and adherence. Positive health outcomes are sustained through increased adherence to treatment, medications and relevant follow-up. Secondly, patient and carer education around managing health conditions and existing services and support can empower individuals to actively participate in care. Utilising technology and e-health resources are useful tools in the community to improve education uptake, patient monitoring and information sharing.

Furthermore, a patient-centred approach to care transitions and communication is paramount. Catering care plans and coordination to the specific needs of patients is the best way to maintain their health and wellbeing in the community. Effective communication and collaboration among primary care clinicians, allied health and community health services are essential to ensure care continuity (Australian Commission on Safety and Quality in Health Care, 2015). Clinicians also need to consider financial constraints, geographical location and access to health services when coordinating care within the community. Without consideration for the social determinants of health, care cannot be adequately individualised, and unmet needs will arise. When these factors are studied, patients and carers are connected to adequate and appropriate social support, which in turn increases engagement and decreases poor attendance or adherence to
medical treatment plans.

Summary
A thorough understanding of transitional care is pivotal in managing the health and wellbeing of older adults living with dementia in the community. People living with dementia and their carers should have a clear and active role in their treatment decisions and the transitional care process. Establishing points of contact and support networks help encourage patient and carer engagement while also creating opportunities for meaningful conversations surrounding care decisions are key strategies to improve patient outcomes. Health services have often shifted to value the impact of the primary care environment on these vulnerable populations, leading to greater quality of life and a decreased strain on acute care settings. With ‘good’ and ‘successful’ transitional care comes effective care coordination, strong communication, thorough care continuity and consistency across the continuum. These combine to enhance the quality of transitional care for older adults living with dementia and their carers.

References

Australian Commission on Safety and Quality in Health Care, Engaging patients in communication at transitions of care., in Prepared by a consortium from Deakin and Griffith Universities. 2015, Australian Commission on Safety and Quality in Health Care: Sydney.

Australian Commission on Safety and Quality in Health Care, Safety issues at transitions of care: Consultation report on perceived pain points relating to clinical information systems. 2017, ACSQHC Sydney.

Manias, E., Bucknall, T., Hutchinson, A., Botti, M., and Allen, J., Improving documentation at transitions of care for complex patients. ACSQHC, 2017.

Naylor, M. and S.A. Keating, Transitional care. American Journal of Nursing, 2008. 108(9 Suppl): p. 58-63.