Planning Elements that Improve Client Safety and Continuity of Care During Transitions:
■ Starting transition planning early, well before discharge;
■ Including the family and caregivers in the planning process;
■ Using client-specific information and education;
■ Communicating effectively with interprofessional team members, clients, their families and caregivers; and
■ Ongoing support of the client after discharge such as referral to community programs or services.