Toolkit: The Transition

Effective Handoff Communication with the Next Setting of Care

Coordinating a successful transition to the next setting (whether to another agency or facility, another unit within the same facility, or to home under the care of community physicians) by employing effective handoff communication.

Tools:

SBAR Technique for Communication

INTERACT's SBAR Communication Form and Progress Note

INTERACT's Hospital to Post-Acute Care Transfer Form

Project RED's Postdischarge Components of the RED (see page 23)

INTERACT's Nursing Home to Hospital Transfer Form

Project BOOST's Patient PASS: A Transition Record (adapt for family caregiver)

Points to Consider: Effective handoff communication is a skill that needs to be learned and practiced. Verbal and written reports that are unorganized are often ineffective and can delay the implementation of essential care, which can put patients at risk for adverse events. 

Reviewing Discharge Instructions with the Family Caregiver

Aiming to make the final discharge instructions with the family caregiver a simple review of what has already been taught.

Tools:

Project BOOST's Discharge Preparation Education Tool (DPET) (adapt for family caregiver)

Teach Back

Going Home: What You Need to Know (discharge checklist for family caregivers)

Family Caregiver's Planner for Care at Home

Medication Management Form (in English, Spanish, Russian, and Chinese)

Project RED Tool 7: Understanding and Enhancing the Role of Family Caregivers in the Re-Engineered Discharge

Points to Consider: Education is about the right information learned at the right time by the right person. Discharges, which are often characterized by stress and confusion, are NOT the right time to begin education and training. The family caregiver who will be doing or assisting with those tasks may not even be present at discharge. A review of previously taught information can be done via telephone with the appropriate family caregiver.

← Go back to Toolkit Home

← Go back to Provider Home