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Practice change on transitional care


Ander Alberdi ,

Osakidetza, ES
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Garbiñe Garin

Osakidetza, ES
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Introduction: Transitional care is a weak point of integrated care. Checklits and protocols have been developed about this issue (1). Many of them consider the transition the time at patient is discharged from the hospital. Anyway the term can be used to describe other pathways patients have to go through.  

Short description of practice change implemented: We are implementing structured transitional care system based on:

1.Creation of a two-way flow control system between primary and hospital care.    

- Done in call center compound by liaison nurses and office administrative.     

- Assures the correct use of several processes:    

- Monitoring chronic processes (call tracking programs, following forms)     

- Telephone handling of the exacerbations (automatismsbased treatment changes, appointment with GP…    

- Direct access to the hospital     

- Appointment with GP at discharge.

 2.Use the same forms to monitor multi-pathologic patients by all levels health providers (HP).

3.Development of transitions form, filled by issuer HP and accessible by recipient at any level. Contains:    

-Wills of the patients.    

-The objectives and the expectations generated in:     


-Exacerbations of chronic pathologies.      

-Convalescence-functional gain.     

-Palliative care.    

-Social intervention.


Aim and theory of change: To reduce the vulnerability that patients suffer in the transitions between the different elements of the system. A structured system, which coordinates protocols already in use and new ones, can reduce the problems that users of health systems encounter when they change from one healthcare element to another. 


Targeted population and stakeholders:

Multi-pathologic and high readmission risk patients.

Nurse home residents.

Patients at the end of live.

Patient´s relatives and caregivers. 



Development transition form.

Development call center.

Diffusion its use among different levels HP.

Measure of results (on going).


Highlights (innovation, Impact and outcomes):

A structured transitional care system.

Coordinates protocols already in use and new ones.

Seeks for improve: Quality perceived by the user. 

Number of:

Errors in medication reconciliation.

Discordant messages.

Agreements of wills respected. 

Follow-up appointments. 



Comments on sustainability. Implies:

the use of programs already underway.

the use of easily developed forms in an integrated EHR already implemented.


Comments on transferability: Adaptable to systems with unified EHR and possibility of using forms.  

Conclusions (comprising key findings): We are implementing structured transitional care, The core of the protocol is:

use of common forms.

develop of call center.

authomatic appointments with GP.

We hope to reduce the vulnerability that patients suffer in the transitions


Discussions: Communication tools between different levels seems to be useful to reduce errors in transitions. Our system based on the use of common forms and automatic citations can be a useful strategy whose results we are measuring.

Lessons learned: Transitions are one of the processes where users feel most vulnerable.

A protocol that coordinates and controls the integrated care measures that are already in operation along with the implementation of new elements (call center, transition forms, appointments of patients at risk of failure) could reduce these fears.


1- J Am Geriatr Soc. 2016 May;64(5):1104-7. doi: 10.1111/jgs.14086. 

How to Cite: Alberdi A, Garin G. Practice change on transitional care. International Journal of Integrated Care. 2019;19(4):426. DOI:
Published on 08 Aug 2019.


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