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Lesson 5: Transition Planning and Coordination CG

Dr. Rob November 30, 2023

Transition Planning and Coordination

Developing a Comprehensive Plan of Care

Transition planning is a pivotal aspect of the healthcare transition process. In this section, we will guide you through the process of developing and regularly updating a comprehensive plan of care for your patients. This plan should encapsulate various elements, including readiness assessment findings, the patient’s goals and prioritized actions, medical summaries, emergency care plans, and, if necessary, condition fact sheets and legal documents.
You’ll learn how to create a roadmap that guides the patient and their family through the transition. By the end of this section, you’ll be proficient in crafting thorough plans of care that ensure a seamless transition to adult-centered care.

Bullet 2: Preparing Patients and Families for an Adult Approach to Care
Preparing patients and their families for an adult approach to care is essential for a successful transition. In this section, we’ll discuss the various aspects of adult care, including legal changes in decision-making, privacy and consent, self-advocacy, and access to information.
You’ll learn how to address these critical components, ensuring that patients and their families are well-informed and comfortable with the transition process. By the end of this section, you’ll be equipped to guide patients and their families through this essential preparation.
Bullet 3: Determining Need for Decision-Making Supports
Some patients may require additional decision-making supports during the transition. This section will help you identify when such supports are needed and how to make referrals to legal resources or other assistance.
You’ll gain insights into assessing the patient’s capacity for decision-making and understanding the legal aspects involved. By the end of this section, you’ll be proficient in determining when and how to provide additional decision-making support to ensure a smooth transition process.