NURS FPX 6610 Assessment 3 Transitional Care Plan

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NURS FPX 6610 Assessment 3 Transitional Care Plan

Student Name

Capella University

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name

Date

Transitional Care Plan

Patient Quality of Care and Safety in Transitional Care

Transitional care plays a crucial role in ensuring patient quality of care and safety, particularly during the transfer between different phases of treatment. This is especially vital for patients with chronic illnesses like diabetes, where continuous monitoring across treatment phases is necessary to prevent adverse outcomes such as mortality (Korytkowski et al., 2022). This assessment focuses on Mrs. Snyder, a 56-year-old diabetic patient admitted to Villa Hospital due to an infected toe. The discussion revolves around formulating a transitional care plan for Mrs. Snyder and addressing communication barriers that may impact the overall plan effectiveness.

Key Elements and Information Necessary for High-Quality Treatment

For effective treatment, strict adherence to guidelines is paramount. Precise diagnosis, continuous monitoring, and meticulous record-keeping are essential (Watts et al., 2020). Key elements required for Mrs. Snyder’s care include:

1. Medical Records: Access to Mrs. Snyder’s medical records facilitates comprehensive understanding and diagnosis, enabling healthcare professionals to address various health issues impacting her well-being (Chen et al., 2018).

2. Medication Reconciliation: Knowledge of Mrs. Snyder’s medication list ensures appropriate treatment and helps prevent adverse drug reactions. Accurate medication reconciliation is crucial for her treatment success (Fernandes et al., 2020).

3. Emergency and Advance Directive Information: Understanding Mrs. Snyder’s religious beliefs and having access to advance directive information aids in providing patient-centered care and ensures continuity of treatment (Dowling et al., 2020).

4. Patient Feedback: Feedback from Mrs. Snyder allows healthcare professionals to tailor treatment plans according to her preferences and needs, enhancing patient engagement and adherence (Moghaddam et al., 2019).

5. Plan of Care and Education: Healthcare professionals must be trained to provide personalized care, and patients like Mrs. Snyder require education on self-management strategies to improve their well-being (Dyer, 2021).

6. Community and Healthcare Resources: Access to community resources and support services is crucial in preventing adverse outcomes such as hospital readmissions and mortality (Yue et al., 2019).

Insightful Assessment of Patient Needs

To facilitate Mrs. Snyder’s transition, comprehensive information transfer is necessary, including medical test results, discharge prescriptions, counseling documents, and current health status (Humphries et al., 2020).

Importance of Key Elements in Transitional Care Plan

Each key element plays a crucial role in enhancing patient care and safety. Advance directive information and medication reconciliation are particularly vital in preventing adverse events (Blackwood et al., 2019; Borulkar et al., 2022).

Potential Effects of Incomplete or Inaccurate Information on Care

Incomplete or inaccurate information can lead to treatment delays, medication errors, and increased mortality rates, highlighting the importance of thorough information transfer (Zirpe et al., 2020).

Importance of Effective Communication

Effective communication is essential for comprehensive information exchange, fostering patient trust, and ensuring timely and appropriate treatment (Garcia-Jorda et al., 2022).

Potential Effects of Ineffective Communications

Ineffective communication can result in treatment delays, health disparities, increased costs, and decreased patient satisfaction, impacting overall care quality (Raeisi et al., 2019).

Barriers to Accurate Patient Information Transfer

Barriers such as staff shortages, incomplete medical histories, and lack of EHR knowledge hinder effective information transfer, necessitating improved planning and communication (Cullati et al., 2019; Tsai et al., 2020).

Strategy to Establish Absolute Understanding of Continued Care

Strategies such as thorough planning, follow-up sessions, and clear communication aid in ensuring accurate information transfer and improving patient outcomes (Glans et al., 2020; Spencer & Singh Punia, 2020).

Conclusion

In conclusion, a well-executed transitional care plan is vital for patients like Mrs. Snyder to ensure seamless transitions between healthcare sectors and prevent adverse outcomes. Effective communication, thorough information transfer, and patient-centered care are essential elements in achieving successful transitions and enhancing overall patient well-being.

References

Moghaddam, M. A.A., Zarei, E., Bagherzadeh, R., Dargahi, H., & Farrokhi, P. (2019). Evaluation of service quality from patients’ viewpoint. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-3998-0

Blackwood, D. H., Walker, D., Mythen, M. G., Taylor, R. M., & Vindrola-Padros, C. (2019). Barriers to advance care planning with patients as perceived by nurses and other healthcare professionals: A systematic review. Journal of Clinical Nursing, 28(23-24), 4276–4297. https://doi.org/10.1111/jocn.15049

Borulkar, R., Dhande, P., & Dhande, P. (2022). Medication Reconciliation: A beneficial tool in patient safety 1 1. Bharati Vidyapeeth Medical Journal (BVMJ), 2(3). https://bvmj.in/journal/borulkar_2022.pdf

Chen, Y., Ding, S., Xu, Z., Zheng, H., & Yang, S. (2018). Blockchain-based medical records secure storage and medical service framework. Journal of Medical Systems, 43(1). https://doi.org/10.1007/s10916-018-1121-4

Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Junod Perron, N., Bajwa, N. M., Viet Vu, N., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & Nendaz, M. R. (2019). When team conflicts threaten the quality of care: A study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43–51. https://doi.org/10.1016/j.mayocpiqo.2018.11.003

Dowling, T., Kennedy, S., & Foran, S. (2020). Implementing advance directives—An international literature review of important considerations for nurses. Journal of Nursing Management, 28(6). https://doi.org/10.1111/jonm.13097

Dyer, E. (2021). It’s about people: Caring agents and satisfied patients are key to a successful healthcare call center culture. Management in Healthcare, 6(2), 134–141. https://www.ingentaconnect.com/content/hsp/mih/2021/00000006/00000002/art00004

Fernandes, B. D., Almeida, P. H. R. F., Foppa, A. A., Sousa, C. T., Ayres, L. R., & Chemello, C. (2020). Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in Social and Administrative Pharmacy, 16(5), 605–613. https://doi.org/10.1016/j.sapharm.2019.08.001

Fiorillo, A., Barlati, S., Bellomo, A., Corrivetti, G., Nicolò, G., Sampogna, G., Stanga, V., Veltro, F., Maina, G., & Vita, A. (2020). The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review. Annals of General Psychiatry, 19(1). https://doi.org/10.1186/s12991-020-00293-4

Garcia-Jorda, D., Fabreau, G. E., Li, Q. K. W., Polachek, A., Milaney, K., McLane, P., & McBrien, K. A. (2022). Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07590-6

Glans, M., Kragh Ekstam, A., Jakobsson, U., Bondesson, Å., & Midlöv, P. (2020). Risk factors for hospital readmission in older adults within 30 days of discharge – A comparative retrospective study. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-020-01867-3

Humphries, C., Jaganathan, S., Panniyammakal, J., Singh, S., Dorairaj, P., Price, M., Gill, P., Greenfield, S., Lilford, R., & Manaseki-Holland, S. (2020). Investigating discharge communication for chronic disease patients in three hospitals in India. Plos One, 15(4), 0230438. https://doi.org/10.1371/journal.pone.0230438

Ilardo, M. L., & Speciale, A. (2020). The community pharmacist: Perceived barriers and patient-centered care communication. International Journal of Environmental Research and Public Health, 17(2). https://doi.org/10.3390/ijerph17020536

NURS FPX 6610 Assessment 3 Transitional Care Plan

Kaper, M. S., Winter, A. F. de, Bevilacqua, R., Giammarchi, C., McCusker, A., Sixsmith, J., Koot, J. A. R., & Reijneveld, S. A. (2019). Positive Outcomes of a Comprehensive Health Literacy Communication training for health professionals in three European countries: A multi-center pre-post intervention study. International Journal of Environmental Research and Public Health, 16(20), 3923. https://doi.org/10.3390/ijerph16203923

Korytkowski, M. T., Muniyappa, R., Antinori-Lent, K., Donihi, A. C., Drincic, A. T., Hirsch, I. B., Luger, A., McDonnell, M. E., Murad, M. H., Nielsen, C., Pegg, C., Rushakoff, R. J., Santesso, N., & Umpierrez, G. E. (2022). Management of hyperglycemia in hospitalized adult patients in non-critical care settings: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. https://doi.org/10.1210/clinem/dgac278

Raeisi, A., Rarani, M. A., & Soltani, F. (2019). Challenges of the patient handover process in healthcare services: A systematic review. Journal of Education and Health Promotion, 8(173). https://doi.org/10.4103/jehp.jehp_460_18

Schultz, B. E., Corbett, C. F., Hughes, R. G., & Bell, N. (2021). Scoping review: Social support impacts hospital readmission rates. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16143

NURS FPX 6610 Assessment 3 Transitional Care Plan

Spencer, R. A., & Singh Punia, H. (2020). A scoping review of communication tools applicable to patients and their primary care providers after discharge from the hospital. Patient Education and Counseling. https://doi.org/10.1016/j.pec.2020.12.010

Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of electronic health record implementation and barriers to adoption and use: A scoping review and qualitative analysis of the content. Life, 10(12), 327. https://doi.org/10.3390/life10120327

Watts, G. F., Gidding, S. S., Mata, P., Pang, J., Sullivan, D. R., Yamashita, S., Raal, F. J., Santos, R. D., & Ray, K. K. (2020). Familial hypercholesterolemia: Evolving knowledge for designing adaptive models of care. Nature Reviews Cardiology, 17(6), 360–377. https://doi.org/10.1038/s41569-019-0325-8

Yazdinejad, A., Srivastava, G., Parizi, R. M., Dehghantanha, A., Choo, K.-K. . R., & Aledhari, M. (2020). Decentralized authentication of distributed patients in hospital networks using blockchain. IEEE Journal of Biomedical and Health Informatics, 24(8), 2146–2156. https://doi.org/10.1109/JBHI.2020.2969648

Yue, D., Pourat, N., Chen, X., Lu, C., Zhou, W., Daniel, M., Hoang, H., Sripipatana, A., & Ponce, N. A. (2019). Enabling services to improve access to care, preventive services, and satisfaction among health center patients. Health Affairs, 38(9), 1468–1474. https://doi.org/10.1377/hlthaff.2018.05228

Zirpe, K., Seta, B., Gholap, S., Aurangabadi, K., Gurav, S. K., Deshmukh, A. M., Wankhede, P., Suryawanshi, P., Vasanth, S., Kurian, M., Philip, E., Jagtap, N., & Pandit, E. (2020). Incidence of medication error in critical care unit of a tertiary care hospital: Where do we stand? Indian Journal of Critical Care Medicine, 24(9), 799–803. https://doi.org/10.5005/jp-journals-10071-23556

NURS FPX 6610 Assessment 3 Transitional Care Plan

NURS FPX 6610 Assessment 3 Transitional Care Plan

NURS FPX 6610 Assessment 3 Transitional Care Plan

NURS FPX 6610 Assessment 3 Transitional Care Plan

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