"...transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.... Transitional care, which encompasses both the sending and the receiving aspects of the transfer, is essential for persons with complex care needs." - (Coleman & Boult, 2003)

"People with chronic conditions must navigate a care system that is ill equipped to meet their needs. The human and economic toll is devastating....We need the political will to change clinical practices and policies in order to implement evidence-based transitional care." - (Naylor, 2008)

In the more than 25 years I have been practicing or managing in home care there have been complaints about the lack of information received from referral sources for admissions. The challenges in transitions of care are nothing new to home care and we have lived with inadequate discharge planning and poor communication(s) for years. Coleman and Boult's (2003) and Naylor's (2008) seminal work on care transitions opened the floodgates of national awareness to the fundamental difference that good care transitioning can make in the health care of all patients, but especially those patients with complex healthcare needs; those patients with multiple and complex health problems-the same population who make up the bulk of our home care patients.

So, on the one hand, we are thrilled that the need for appropriate care transitioning is on everyone's agenda, while, on the other hand, we must step up and admit that home care has a responsibility to the success of the process, both once the patient comes to us and as we transition the patient to other care providers. This means that home care must recognize that communication is a two-way street and we need to ensure that we are providing quality communication(s) and documentation to all members of the patient's health care team and family.

As healthcare moves toward accountable care organizations, patient-centered medical homes, and bundled payment mechanisms, the focus is on the physician practice and the hospital as the key drivers in appropriate care transitions. Home care agencies need to make their voices heard as experts in community-based patient care and seek ways to work with hospitals and physicians to forge new alliances for care. In this issue of Home Healthcare Nurse, Mary Deveau's VNAA column speaks to "The Complexity of Care Transitions" and the role home care must play to ensure that our patient's needs are met.

The good news is that as home health agencies, we have a strong family of colleagues who are all "in this" with us, and we have the opportunity to learn from each other. Sally Sobolesweski's great article, "The Challenge of Improving Transitional Care: Lessons Learned in a Home Health Care Agency" offers excellent lessons learned when a large agency is invested in impacting positive, systematic change to their home care transitional care processes.

Both Coleman and Boult (2003) and Naylor's (2008) work cite medication reconciliation as one of the key elements in successful care transitions models. Sara Butterfield and Anne Myrka's article, entitled "A System-Based Medication Reconciliation Process With Implications for Home Health Care," demonstrates how one hospital system addressed this problematic and multifaceted issue. Her article offers insight into medication reconciliation from a pharmacist's viewpoint and provides resources and tools they used to demonstrate a decrease in their rehospitalization rates through improved medication reconciliation.

One of the fundamental challenges in home care is appropriate documentation and now, more than ever, we are "living and dying" by our clinicians' documentation. This is an even bigger issue in hospice as increasingly regulations require hospices to demonstrate medical need through evidence-based clinical documentation for all disciplines. Barbara Ivanko's CE article on how social workers in her hospice learned to embrace evidence-based practice documentation is a must read for hospices struggling with this issue and provides insights for home care agencies who want to help their social workers work on improved documentation.

Knowledge is Power

Those often-quoted words continue to ring true, but in this day of Internet access and more journal articles than I could ever hope to read, I often feel I am missing essential knowledge that I need!! Imagine my delight when I read the article on the Visiting Nurse Association of Central Jersey's journal clubbies Susan Fowler, Kim Druist, and Lisa Dillon-Zwerdling. What a great idea!!

But I still have the challenge of too many articles, not enough time. This month's Research Brief Column comes to the rescue with the latest research related to transitional care with a focus on implications for home care. Thank you, Melissa Trachtenberg and Miriam Ryvicker, for culling through the recent research and finding three articles that helped me further my knowledge and learn how I can use this information to improve my agency's work on care transitions.

Finally, don't miss Part II of the article "OASIS-C Importance of Accurate Pressure Ulcer Assessment and Management in Home Health Care." This important CE article by Yanick Martelly-Kebreau and Mary Farren offers concrete examples of the connection between clinical assessment, interventions, documentation, and the impact on clinical outcomes. Use this article as a teaching tool for all your clinicians to understand how to document what they are seeing and doing appropriately in OASIS.

Grab a cup of tea, coffee, or the libation of your choice, your highlighter, and Home Healthcare Nurse, sit in a comfy chair, and enjoy this great issue on care transitions.

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