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Evaluation

Clinical Medicine

(SA13) Implementing Transitional Care in PALTC: Real-World Reports and Approaches

Saturday, March 9, 2024
12:30 PM – 4:00 PM CT
Room: 303
CMD Clinical Credit
CME: (3.5) MOC: (3.5) CMD Clinical: (3.5) NP Pharmacology Hours ()
Disclosure(s):
Sing T. Palat, MD, CMD: No financial relationships to disclose.
Mark Toles, PhD, RN: No financial relationships to disclose.
Danny W. Felty, MD, CMD, FAAFP: No financial relationships to disclose.
Lora Crowe, PhD, FNP-BC: No relevant financial relationships.
Mamata Yanamadala, MBBS, MS: No financial relationships to disclose.
Cecilia Y. Cai, MD, CMD: No financial relationships to disclose.
Joseph Marek, RPh, BCGP, FASCP: No financial relationships to disclose.
Post-acute long-term care (PALTC) leaders have long advocated for improving transitions of care. Yet, challenges implementing transitional care often limit improvements in care. In this workshop, explore real world reports on implementing transitional care, such as pharmacist-supported consultation in SNFs, team-based discharge planning, and telehealth supported follow-up after discharge. Join breakout groups, facilitated by interdisciplinary team leaders, to explore implementation strategies (such as learning collaboratives) and quality metrics (such as reach and fidelity) to ensure effective and equitable transitions of care. Current research will be presented for PALTC leaders and providers to (1) identify transitional care needs, (2) implement transitional care, and (3) lead clinical teams as they adopt new transitional care practices.

*This session is in-person in San Antonio ONLY. It will not be livestreamed or recorded.

Learning Objectives:

At the completion of this session, learners will be able to:
  • Identify unmet transitional care needs, such as transfers from nursing homes to ED and follow-up care after SNF discharge.
  • Apply an evidence-based framework to implement transitional care and address needs
  • Describe strategies to implement transitional care in PALTC settings, such as using learning collaboratives to engage team members and foster change.
  • Identify reliable measures to evaluate the quality of transitional care, such as fidelity to the plan for change and reach to patients.