Transitional Care

BioScience Trends. 2021; 15(1):55-57.
55
Communication DOI: 10.5582/bst.2021.01056
Transitional care during COVID-19 pandemic in Japan: Calls for

new strategies to integrate traditional approaches with information
and communication technologies
Yuka Sumikawa*, Noriko Yamamoto-Mitani
Department of Community Health Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo,
Bunkyo-ku, Tokyo, Japan.
SUMMARY Transitional care is indispensable in successfully transitioning patients from hospital to home and
preventing adverse events during this process. There were restricted services in several hospitals for
minimizing the spread of COVID-19. Therefore, hospitals could not provide adequate transitional
care that possibly resulted in poor post-discharge outcomes in patients. Some hospitals have now
combined infection prevention with face-to-face opportunities, i.e., requiring reservations for
transitional care consultation and restricting pre-discharge conferences. Several hospitals started
providing pre-discharge conferences using apps, where patients/family caregivers and care teams
could have face-to-face discussions about medical and nursing care plans, goals, and preferences.
However, building a relationship between patient/family and medical/nursing staff and providing
decision-making, psychological support, and risk assessment generally performed in person are still
in demand. New hybrid strategies should be developed and evaluated to provide transitional care
while using online systems and minimal face-to-face support during the pandemic.
Keywords COVID-19, discharge, transitional care
1. Introduction family caregivers during the COVID-19 pandemic in

Japan, and they need to be developed and evaluated.
Transitional care is indispensable to successfully guide
patients from hospital to home and to prevent adverse 2. Traditional transitional care system in Japan
events in this process, making it essential for efficient
medical and nursing practice (1,2). One of the most In Japan, a new healthcare reimbursement scheme
important components of excellent transitional care is was introduced to the universal healthcare coverage
active involvement of patients and family caregivers system in 2008 to provide transitional care. Discharge
(1,3,4). Previous studies show that their involvement planning nurses (DPNs) are crucial professionals of the
has improved physical and mental outcomes for interdisciplinary team on transitional care because they
the person who is discharged from the hospital and assist patients with severe conditions, including those
improves continuity of care (5). with terminal cancer or cognitive impairment, who are
In the traditional transitional care system, family highly dependent on medical and long-term care, and
caregivers frequently visited the hospital and acquired arrange their transfer to a local medical institution or
face-to-face services, including information sharing their homes (6).
about continuous care and treatment, medical/nursing "Creating a plan for transitional care with patient
care education, and participation in medical decision- or family caregivers' involvement" is included in
making. Many hospitals have restricted in-person visits requirements before processing hospital bills. Hospital
to minimize the spread of Coronavirus disease 2019 staffs, including DPNs, are required to discuss
(COVID-19) for the safety of the patients, visitors, and patients' medical conditions and life after discharge
staff. As a result, provision of adequate transitional and create a transitional care plan with associated
care is hampered, possibly resulting in poor patient professionals. DPNs provide transitional care strategies
outcomes after discharge. New hybrid strategies are by combining individual care, family caregivers, and a
required for transitional care involving patients and multidisciplinary collaborative team approach.
www.biosciencetrends.com
56 BioScience Trends. 2021; 15(1):55-57.
3. Current status of patients and family caregivers' provide the service mainly in the first one to two weeks
involvement in transitional care during COVID-19 immediately after discharge from the hospital, when
the patient's condition is likely to change, and various
During the COVID-19 pandemic, from March 2020, difficulties are likely to arise. This service effectively
many hospitals prohibited inpatient visitation, even for compensates for the lack of pre-discharge medical and
family members or friends. As of January 2021, these nursing guidance and decision support in a pandemic
restrictions continue at many hospitals. Therefore, situation.
family caregivers are unable to visit patients during However, building a relationship between family
hospitalization and, thus, may not fully understand caregivers and medical/nursing staff, decision-making,
their status. One frontline DPN reported that family psychological support, and risk assessment generally
caregivers, particularly the elderly, were confused about performed in face-to-face communication is still
patients' hospital discharge and service adjustments due demanding. The future challenge is how to promote and
to limited shared decision-making or information for involve patients and caregivers in their transitional care
medical and nursing care plans after discharge, which after discharge while aiming at preventing infection
might have increased caregivers' anxiety and resulted in because especially the time spent between patients
discharge refusals. and their families in the terminal period is extremely
Many patients with terminal illness or caregivers important. Transitional care staff, including DPNs,
opted for discharge to their home to prioritize their time should not wait for the pandemic to converge. New
together. For example, some hospitals were restricted hybrid strategies should be developed and evaluated to
from holding face-to-face discharge conferences with provide transitional care while using online systems and
patients, families, and multidisciplinary specialists. minimal face-to-face support during the pandemic.
Therefore, the DPNs reported that these patients and
caregivers might not have been able to make adequate Funding: This work was supported by the Ministry of
decisions regarding care plans, including their goals Education, Culture, Sports, Science and Technology,
and preferences after discharge. Japan (20K23188).
4. New strategies for a smooth transition from Conflict of Interest: The authors have no conflicts of
hospital to home with COVID-19 measures interest to disclose.
To counter the COVID-19 pandemic, new strategies References

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8. The Cancer Institute Hospital of JFCR. Come join us
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Released online in J-STAGE as advance publication February
Received February 3, 2021; Revised February 10, 2021; 23, 2021.
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BioScience Trends. 2021; 15(1):55-57.

Communication DOI: 10.5582/bst.2021.01056

Transitional care during COVID-19 pandemic in Japan: Calls for

Keywords COVID-19, discharge, transitional care

1. Introduction family caregivers during the COVID-19 pandemic in

To counter the COVID-19 pandemic, new strategies References

End-of-Life-Care.pdf (accessed February 1, 2021). Accepted February 14, 2021.

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