INTRODUCTION

Transition is a period in which something undergoes a change and passes from one stage to another.
Transitional Care refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change.
Specifically, they can occur:
- Within settings
- Between settings
- Across health states
- Between providers

Meaning

Transitional care is a range of time limited services and environments that are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple health care team members and across settings such as hospitals to homes.

Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.
ICU transitional care define as care provided before, during and after the transfer of an ICU patient to another care unit that aims to ensure minimal disruption and optimal continuity of care for the patient

Critically ill patients in the intensive care unit often experience a lot of changes as they move through different levels of care.

Barriers to effective care transitions at three levels:

The Delivery System
- The lack of formal relationships between care settings represents
- Lack of financial incentives promoting transitional care
- The lack of information systems designed to facilitate the timely transfer of essential information.
The Clinician
- Nursing staff shortages
- Clinicians do not verbally communicate patient information to one another across care settings.
The Patient Barriers
- Lack of advocacy or outcry from patients for improving transitional care until they or a family member is confronted with the problem firsthand.
- Older patients and their caregivers often are not well prepared or equipped to optimize the care they will receive in the next setting.
- They may have unrealistic expectations about the content or duration of the next phase of care and may not feel empowered to express their preferences or provide input for their care plan.
- Patients may not feel comfortable expressing their concern that the primary factor that led to their disease exacerbation was not adequately addressed.

Transition as a concept is central to the nursing discipline as a whole. Nurses often are the primary health professionals involved in encounters with patients and their families that relate to transitional periods of instability.
The Transitional Care Nurse (TCN) follows participating patients from hospitals into their homes, and using an evidence-based care coordination approach, provides services designed to streamline plans of care and interrupt patterns of frequent acute hospital or emergency department use and health status decline.

The TCN role is very different from a traditional nursing position. It incorporates the skills of a nurse, care manager, and patient advocate and knowledge of evidence-based care, managing complexity, palliative care, active engagement of family caregivers, interdisciplinary team care, theories and strategies for individualized care and behavioral change, quality improvement, and organization, delivery and financing of services across an episode of acute care.
Healthcare transitions ensure safe and efficient movements of patients between different sectors of care within the healthcare system.
Transition as a concept is central to the nursing discipline as a whole. Nurses often are the primary health professionals involved in encounters with patients and their families that relate to transitional periods of instability.