A sharing by Low Lian Leng and Tay Wei Yi
Change is situational. Transition, on the other hand, is psychological. It is …. the inner reorientation or self-redefinition that you have to go through in order to incorporate any of the changes into your life.
—-William Bridges
The above quote describes organizational transition, but it applies just as much to our patients’ journeys from hospital back to family, community, and society. The aim of transitional care is to segue a patient from the safety of one to care and life in the other, recognizing that as the team deals with the external, the patient himself is having to deal with the internal.
Broken Pieces
Kevin* had poorly controlled diabetes. He was fifty, embittered, and grieving. He had started his journey with two gangrenous left toes that eventually ended with an above knee amputation and a sacral sore from prolonged bed rest. The transitional care team took over his care on his discharge from the acute hospital a week after his amputation.
In the following six months, we worked with Kevin on his understanding of his disease and coached him through glucose monitoring and insulin challenges. The nurses dressed his stump wound and his sacral sore. He received reminders to attend his outpatient appointments and encouragement to persist with exercises at home. We paid special attention to his mood as he coped with his life-changing loss. At six months post-amputation, he was fitted with a prosthesis and started looking for a job.
Kevin has grappled with internal demons and external beasts to get where he is. This is successful care transition.
Commentary
Transitional care is especially vital to aid our patients with multiple morbidities and complex biopsychosocial needs as they move from an acute care setting back to their community.
This involves medical care and equipment support, but also includes patient education, encouragement, and empowerment, and connecting the patient to various community resources. The complex patient has more than one domain of need. Therefore, good transitional care needs to be provided by a team that spans medical, nursing, allied health, and social disciplines.
In the drawing, a man who is a double amputee, sits on a wheelchair in his home. However, his home is several feet underground, and there is a tombstone at ground level. He is in a living grave. The flowers bloom in the world above, which is not slowing to accommodate the man and his disabilities.
What we hope to see is another drawing, this time with the amputee patient smiling, in a home above ground, physically and emotionally linked to his surroundings. Good transitional care seeks to achieve this.
Drs Low Lian Leng and Tay Wei Yi
*Name has been changed
Low Lian Leng is a family physician in a tertiary hospital. He is passionate about population health, aging and integrating health and social care.
Tay Wei Yi practices in a tertiary hospital and also actively teaches postgraduates. She is passionate about nurturing future generations in the breadth of Family Medicine.
The commentary and the vignette were reproduced with permission from the book ‘Being Human, Stories from Family Medicine’ edited by Cheong Pak Yean and Ong Chooi Peng and published in 2021 by the College of Family Physicians Singapore.
Pictures of illness experiences were drawn by NUS medical students in workshops conducted from 2012-2017 by A/Prof Cheong Pak Yean. Senior family physicians subsequently shared vignettes and commentaries based on the pictures.
