Best Practices in Transitions in Care for RN and Social Work Case Managers, Staff Nurses, and Physicians

Product Id : HLT97
Instructor : Toni G. Cesta
Jun 21, 2023 12:30 PM ET | 11:30 AM CT | 09:30 AM PT | 90 Minutes


Transitions in care have become an important component in the treatment of patients. New and advanced payment methods such as bundled payments and accountable care organizations, as well as readmission reduction programs, have drawn more attention to this vital element of patient care delivery.  Transitions occur when patients move from one level of care to another, whether within the acute care setting or beyond the walls of the hospital.  During times of transition, information transfer is critical, yet handoff communication is sometimes neglected or performed as an after-thought. When this happens, care can be compromised, resulting in poor patient outcomes, readmissions, and higher cost. 

This webinar will review best practices in transitioning patients, the pitfalls, communication streams, and the need to keep the patient in the center of the process. We will discuss the relationship between discharge planning and transitions and how these roles work together.  Additionally, we will discuss hand-offs, what they are, and how to ensure that you are performing your handoffs in ways that will ensure the best transitions of your patients and their families. Each member of the interdisciplinary care team performs handoffs and has the responsibility of ensuring that they are thorough, complete and timely. 

What Attendees Will Learn:

  • Understand the differences between discharge planning and transitions in care.
  • Describe the best practices in hand-offs and the regulatory requirements associated with them.
  • 3Discuss the risks and poor outcomes associated with inadequate transitions.
  • Discuss strategies for effective handoffs across the continuum.
  • Review ways in which to ensure that your handoffs reflect best practice
  • Learn how to engage patients and families in handoffs and transitions in care.
  • Develop transitional care plans using best practices.

Area Covered in this session:

  • Changes in discharge planning
  • Moving from discharge to transitions
  • Geography of transitions in care
  • Definition of the continuum of care
  • ACMA Transitions in Care Standards
  • Goals of effective transitions
  • Transitional planning process
  • Transition challenges
  • Handoff communication including best practices
  • Influences on transition related to patients and families
  • Influences related to physician practices
  • Influences related to payers and regulations
  • Influences related to internal hospital processes
  • Influences related to case management
  • Influences related to next levels of care
  • Adopting interventions to improve transitions 
  • Who Should Attend?
  • Chief Executive Officer (CEO)
  • Chief Operating Officer (COO)
  • Chief Nursing Officer (CNO)
  • Chief Medical Officer (CMO)
  • Joint Commission Coordinator
  • Quality Improvement Coordinator
  • Risk Managers
  • Nurse Educator, Staff Nurses, Nurse Managers
  • Patient Safety Officer
  • Emergency Department Manager
  • Compliance Officer
  • Consumer Advocates
  • Clinic Managers
  • OR Nurse Director
  • Lab director
  • Policy and procedure committee
  • Ethicist
Speaker Profile:

Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models, with an eye on structure, process and outcome measures for nurse case managers and social workers.

The author of nine books on case management, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management. Among her books are included the “The Case Managers Survival Guide” and “Core Skills for Hospital Case Managers”.

Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management newsletter in which she shares insights and information on current issues and trends in case management.  She is a past commissioner for the Commission for Case Management Certification. She has held positions as Senior Vice President, Corporate Vice President, Director of Case Management and professor of case management.

Available Options

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