Purpose and scope
This guideline provides evidence-based recommendations for nurses and other members of the interprofessional team who are assessing and managing clients undergoing a care transition.
The guideline focuses on building the core competencies and concepts proven to facilitate safe and effective care transitions that maintain continuity of care and promote optimal outcomes for clients. Safe and effective care transitions – whether within, between or across settings or services – depend on coordinated interprofessional care and ongoing communication among professionals and clients.
We’ve designed this guideline to help nurses and their interprofessional teams become more comfortable, confident and competent when caring for clients undergoing care transitions. It is intended for use in all domains of health care and public health, including clinical work, administration and education.
Who's using this?
Registered Nurses’ Association of Ontario (2014). Care Transitions. Toronto, ON: Registered Nurses’ Association of Ontario.
Do you want to learn about and implement the most- up-to-date evidence-based recommendations on this topic with your colleagues? Download and share the full best practice guideline (BPG), Care Transitions.
See below for a snapshot of the recommendations from this BPG. We strongly suggest you review the full BPG before implementing the recommendations and good practice statements. The BPG also includes further resources to support implementation and evaluation.
Recommendation 1.1: Assess the client’s current and evolving care requirements on admission, regularly throughout an episode of care, in response to a change in health status or care needs, at shift change and prior to discharge.
Recommendation 1.2: Obtain a “best possible medication history” during care transitions by using a structured and systematic process to collect client medication information that includes dose, frequency and route.
Recommendation 1.3: Assess the client for physical and psychological readiness for a care transition.
Recommendation 1.4: Assess the client, their family and caregivers for factors known to affect the ability to learn self-care strategies before, during and after a transition.
Recommendation 1.5: Assess the learning and information needs of the client, their family and caregivers to self-manage care before, during and after a transition.
Recommendation 2.1: Collaborate with the client, their family and caregivers and the interprofessional team to develop a transition plan that supports the unique needs of the client while promoting safety and continuity of care.
Recommendation 2.2: Use effective communication to share client information among members of the interprofessional team during care transition planning.
Recommendation 3.1: Educate the client, their family and caregivers about the care transition during routine care, tailoring the information to their needs and stage of care.
Recommendation 3.2: Use standardized documentation tools and communication strategies for clear and timely exchange of client information at care transitions
Recommendation 3.3: Obtain accurate and complete client medication information on care transition
Recommendation 3.4: Coach the client on self-management strategies to promote belief in their ability to look after themselves on care transition.
Recommendation 4.1: Evaluate the effectiveness of transition planning on the client, their family and caregivers before, during and after a transition.
Recommendation 4.2: Evaluate the effectiveness of transition planning on the continuity of care
Recommendation 4.3: Evaluate the effectiveness of communication and information exchange between the client, their family and caregivers and the health-care team during care transitions.
Recommendation 5.1: Health-care professionals engage in continuing education to enhance the specific knowledge and skills required for effective coordination of care transitions.
Recommendation 5.2: Educational institutions and programs incorporate the guideline, into basic and interprofessional curricula so all health-care professionals are provided with the evidence-based knowledge and skills needed for assessing and managing client care transitions.
Recommendation 6.1: Establish care transitions as a strategic priority to enhance the quality of client care and safety.
Recommendation 6.2: Provide sufficient human, material and fiscal resources and adopt organization-wide structures necessary to support the interprofessional team with client care transitions.
Recommendation 6.3: Develop organization-wide standardized policies and structured processes for medication reconciliation on care transition.
Recommendation 6.4: Establish organization-wide systems for communicating client information during care transitions to meet all privacy, security and legislated regulatory requirements.
Recommendation 6.5: Include care transitions when measuring organization performance to support quality improvement initiatives for client outcomes and interprofessional team functioning.
Disclaimer: These guidelines are not binding for nurses, other health providers or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.
Current edition published 2014.
About the next edition:
- Anticipated publication date: 2023
This new edition will revise the previous edition BPG:
- Care Transitions (2014)
Anticipated purpose and scope:
This second edition BPG will include evidence-based recommendations for nurses and other members of the interprofessional team, organizations and the health system to support safe and effective transitions in care for pediatric and adult persons and their support network. Broadly, this BPG will focus on transitions between and across settings including, but not limited to: primary care, home and community care, mental health and substance use health settings, acute care, rehabilitation, long-term care, and other social care settings. Best Practice Spotlight Organization Ontario Health Teams (BPSO OHTs) will be implementing this second edition BPG and therefore, this BPG is being developed through co-creation with BPSO OHTs to ensure the recommendations support integrated care across sectors.