Safely and effectively transitioning patients to and from the hospital and receiving patients from the hospital are fundamental to improving transitional care. Obtaining timely patient information after patients return to dialysis from hospitalization has always been a major area of concern. An effective communication process is essential to ensure safe patient hand-offs between healthcare settings and should require the active participation of both a sending provider and a receiving provider.
Establishing a good system of communication between healthcare settings is the key to successful care transitions. Every facility has different circumstances, faces different barriers and will have different processes. No process is right or wrong and may change over time.
You can also use the Forum of ESRD Networks Care Transitions Toolkit