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HCAHPS Breakthrough Blog

The 3 C's

Posted: Wed, Feb 18, 2015 07:43

Always remember the 3 C’s that are crucial to better care transitions: you have to be great communicators, great collaborators, and great coordinators.

Consider This:


Sentara Health in Northern Virginia recommends that the following information be easily in view: patient’s information (name, identifiers, age, sex, and location), the (care) plan (diagnosis, treatment, next steps), the (care) plan rationale (which everybody must understand, including patients and family caregivers), problems (to streamline transfer of responsibility, explain what’s different or unusual about this patient), and precautions (explain what’s expected to be different). You have a checklist of five P’s as you communicate during a transition of care. It’s the essential connection between doctors, nurses, patient, and family.

Draw up a checklist of skills for managing patient expectations. Are you preparing people for the discomfort/pain/low energy levels after surgery, anesthesia, and illness? Are you managing their expectations around communication between various caregivers they’ll see post-discharge? How will you make patients comfortable speaking up about their care? Here’s how: manage expectations about resuming normal activities. Teach family caregivers to help patients get their bearings back before engaging in activities like driving or athletics, thinking they’re well when they should still be healing.


Make sure to pay attention - physicians and nurses in a busy facility don’t know all of a patient’s history, because people are pushed through the system so quickly. Time must be made for this conversation: caregivers need to know their patient’s back-story and share with each other for maximum transition effectiveness. Various disciplines need to collaborate with other departments as well as the patient and family. A patient can seem alert and oriented upon initial assessment, but cognitive deficits are often not immediately noticed. Folks from other departments, or people who are providing other services, get a chance to take a second or third look at that patient. They might notice something that was innocently missed, and they can alert other people.


Everyone involved in the transition have to be on the same page. Transition planning must begin with the patient and the family. Case Managers and the transition team need to meet early on with family to determine the arrangements necessary to keep a patient safe during transition. The critical transition skill is to manage the patient’s expectations. If you take nothing else from this webinar, take this: life changes dynamically after discharge. Patients must go, and we must prepare them to be responsible, active, and outspoken about their well-being. In a hospital, you’re being told what to do and when to do it. Sometimes you get into a routine and it’s kind of comfortable to not have any responsibility – we have to get them to turn that corner. Teach patients and families how to take an active role in care transition and how to manage predictable post-discharge events.

The Take Away:

The 5 P’s (Patient Information, Plan, Plan Rationale, Problems, Precautions) and 3 C’s (Communicate, Collaborate, Coordinate) are essential to smooth care transitions. Remember them however you can (make note cards– you can sing them if it helps), just don’t let a good experience end with a terrible transition!

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