Purpose & Scope

• Transitions need to involve the rights of clients
• Care transitions can occur within organizations (internal) or between them (external)
• Transitions require standardized processes, especially for communication and the flow of information (written or verbal), and particularly when it comes to medication reconciliation
• This guideline focuses on building the core competencies and concepts known to facilitate safe and effective transitions – those that maintain continuity of care and promote optimal outcomes for the client
• Care transitions require comprehensive plans that include both the logistical arrangements needed to move from one setting to another as well as the care involved in moving the client
• Care transitions are coordinated among knowledgeable health-care providers familiar with the client’s clinical status, the goals for his or her health care, and the education required for clients and their families and caregivers (Coleman & Boult, 2003; National Transitions of Care Coalition [NTOCC] Measures Work Group, 2008; Snow et al., 2009)
• Care transitions has been defined as a set of actions designed to ensure the safe and effective coordination and continuity of care as clients experience a change in health status, care needs, health-care providers or location (within, between or across settings)
• Individual nurses will perform only the care they have the education and experience to offer
• This guideline is designed to apply to all domains of nursing practice, including clinical, administration, and education, to assist nurses to become more comfortable, confident and competent when caring for clients undergoing care transitions
• Effective care transitions depend on coordinated interprofessional care that emphasizes ongoing communication among professionals and clients