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Transitional Care Solutions works along with the staff of our Mission Point facilities to make transitioning for our residents easy.  We offer solutions and resolutions for our residents to transition safely to their homes or assist with transitioning solutions for next stage placement for residents.  Consistent communication as it relates to the needs of our residents prior to discharge is key.  Communication between staff and care providers in the form of handoffs remains the primary method to assure continuity of care.  The Key root cause of failed transitions include poor provider communication, ineffective assessments or education of residents/caregiver needs, or the lack of a timely outpatient follow-up, or failure to address the post discharge needs early on.  The discharge process has been shown to begin as time progresses to a resident discharging from our facilities and may not dictate a complete picture of the residents needs prior to discharge.  If we are pro-active in determining our residents’ needs earlier; if we begin the proactive process of systematic review and begin the discussion of the needs at admission, this could positively assist with post discharge planning and placement and have a huge impact on keeping our residents out of the hospital setting and offering an option for outpatient therapy or a welcomed return to our facilities.  The Transition Process of care has emerged as an important point of vulnerability in the health care system where errors of planning have occurred.  Transitional Care Solutions represents a systems-based approach for Mission Point HealthCare Services to guarantee a quality and safe wellness component for our residents.  Transitional Care Solutions is the key element of our attempt to improve our continuum of care and our institutional support.  A multidisciplinary team-based effort, data collection for monitoring achievement of goals, assessing needs of our residents and family engagements, offering education, resources, and standardized discharge pathways, to include the post-discharge follow-up is key to our success.

TRANSITIONAL CARE SOLUTIONS will assist in BRIDGING the GAP for a positive, safe, and seamless transition from our facilities to their home.  

Portia M. Bullard
Director, Transitional Care Solutions