Transitional Care Plan

Patient quality of care and safety also depends upon transitional care. The purpose of transitional care is to provide advanced facilities and services when patients are transferred from one treatment phase to another. Especially in chronic illness, patients must be monitored continuously in every phase of treatment to avoid mortality, which a transactional care plan can do. This assessment discusses the case of Mrs. Snyder 56-year-old patient who has diabetes and comes up in Villa Hospital with the issue of an infected toe. This assessment is designed to discuss the transitional care plan for Mrs. Snyder and what communication berries can affect the overall transitional plan (Korytkowski et al., 2022). 

Key Elements & Information Needed for High-Quality Treatment 

Patient quality of care and safety can be improved only when strict guidelines are in place to assure effectiveness. The Patient’s diagnosis must be made with precision and effectiveness to avoid complications (Watts et al., 2020). Additionally, it is also important that the organization track patient medical records continuously and store them for future needs. In order to understand Mrs. Snyder’s issues, it is important to diagnose her properly. 

NURS FPX 6610 Assessment 3 Transitional Care Plan

Key Elements 

Various key elements and information is needed from Mrs. Snyder to improve her quality of treatment. 

• Medical Records 

One of them is to collect the medical records of Mrs. Snyder, with which her problem can be addressed easily. With the help of Mrs. Snyder’s medical records, staff can diagnose other health problems affecting patient health, like depression, high BP, and heart issues (Chen et al., 2018).

• Medication Reconciliation

In addition to medical records, healthcare staff also needs to know about the medicine list that Mrs. Snyder is taking. The medicine list ensures whether Mrs. Snyder’s medicine benefits her health or if she needs other substitutes. So proper medication reconciliation is necessary to improve Mrs. Snyder’s quality of treatment (Fernandes et al., 2020).   

• Emergency and Advance Directive Information

A transactional care plan demands patient-centered care as staff must focus on Mrs. Snyder’s religious mindset, which will help her in various treatment steps. It is also important for healthcare sectors to get advance directive information about the patient from primary healthcare providers to learn about the treatment the patient is getting in the previous health sector to avoid serious issues (Dowling et al., 2020). 

• Patient Feedback 

Along with this, another key element includes patient feedback regarding medical personnel behavior and treatment process. This will help to know about Mrs. Snyder’s medical needs and wants, so healthcare professionals must provide Mrs. Snyder with all the important information regarding her condition and treatment process. This will encourage the patient to focus on her health care and avoid activities affecting her health (Moghaddam.A.et al., 2019). 

• Plan of Care and Education 

Another key element is that healthcare professionals are also well-trained to provide the best care treatment to the patients with satisfied patient satisfaction. Every patient have different needs and wants, so it is important to develop a transitional care plan according to patient requirement and conditions. Healthcare professionals are responsible for providing patients with various community-based healthcare services and sharing information rapidly with other healthcare professionals (Dyer, 2021).

• Community and Health Care Resources

Avoiding negative medical outcomes like hospital readmissions and mortality rates requires sufficient community services like mobility options, social support, health education, and outpatient treatment (Yue et al., 2019).

Insightful Assessment of the Patient’s Needs

Information needed to transfer Mrs. Snyder to another healthcare sector is medical test results, a list of Mrs. Snyder’s post-discharge prescriptions, and time spent in the previous hospital. Additionally, Mrs. Snyder’s counseling documents, follow-up plans, social assistance and insurance coverage documents, Mrs. Snyder’s current health condition, enhanced safety risk assessments, and thorough treatment and drug history associated with chronic diseases are also required (Humphries et al., 2020). 

Importance of Key Elements of a Transitional Care Plan

Every key element is essential in transitional care plans with which patient quality of care can be improved. It is important to collect patient emergency and advance directive information from previous healthcare sectors so that healthcare professionals prepare for every issue that can come up in the treatment and how to resolve them. It will also help to know about Mrs. Snyder’s religious and cultural beliefs to avoid conflicts. In their literature review, Blackwood et al. (2019) suggested that advance directive helps make future health decisions. Advanced care planning will help to assess patients’ needs and wants. 

In the case of Mrs. Snyder, community and healthcare resources will help to resolve her concerns. She is suffering from an infected toe, so she should have walking problems that can be resolved if she gets room on the ground floor or if the organization has elevator facilities. She also needs a wheelchair to move from one ward to another, so hospitals must ensure they have sufficient facilities to avoid serious complications. In the journal, Schultz et al. (2021) provide the importance of healthcare services and community support to prevent hospital readmission rates. Moreover, they also said that patients need medical services and facilities after discharge to avoid serious issues (Schultz et al., 2021).  

Along with this, medication reconciliation plays an important role as it will help access the medicine the patient is allergic to so that medication errors will be avoided. Along with this, patient readmission rates should also be avoided. Medication reconciliation will also address that Mrs. Snyder is on insulin, so healthcare staff must provide her with accurate insulin doses to prevent dangerous consequences. Borulkar et al. (2022), in their journal, give a viewpoint that medical reconciliation can help to avoid medication errors in healthcare organizations. Their journal focuses on the importance of medication reconciliation towards patient care treatment and safety (Borulkar et al., 2022).

With patient feedback, staff can assess patient concerns towards treatment. Mrs. Snyder suffered from a serious toe infection due to less awareness about post-discharge guidelines, which led her to readmit to the hospital. So healthcare staff requires patient feedback to avoid this type of negligence while treating her. Fiorillo et al. (2020) provide a literature review and describe that patient feedback is necessary to make a treatment decision. Staff will learn about patient concerns through feedback (Fiorillo et al., 2020).

Additionally, healthcare professionals and patients’ advanced training could help to improve Mrs. Snyder’s quality of care. With training, healthcare professionals learn about effective collaboration and communication, which will help to assess patients’ religious and cultural beliefs. Additionally, educating Mrs. Snyder is significant so that she can adopt self-management tactics (eating healthy food and going for walks daily) to improve her well-being and lifestyle. Every patient has different requirements and treatments, so it is important to develop a care plan according to patient requirements. In their case study, Kaper et al. (2019) provide a review that training is necessary for healthcare professionals and patients to avoid mortality rates and improve patient quality of care (Kaper et al., 2019).

NURS FPX 6610 Assessment 3 Transitional Care Plan

Potential Effects of Incomplete or Inaccurate Information on Care

Transferring complete information about patients from one healthcare sector to another is important, as incomplete information can cause delays in treatment and serious complications. Along with incomplete information, if the information is inaccurate, it can cause serious consequences like wrong treatment, increased mortality, and readmission rates. Incomplete information can also cause medication errors. Staff will not get an accurate medication list of patients, and they can give the wrong medicine, which can have an adverse effect on patients. In their literature review, Zirpe et al. (2020) provide a review that an incomplete prescription list can also cause medication errors. Incomplete drug information delays treatment and increases mortality rates within healthcare organizations (Zirpe et al., 2020).  

Importance of Effective Communication

Effective communication with other healthcare agencies is necessary to know about patients’ medical history in detail. Effective interaction is essential in developing a positive interaction between the patient and the healthcare staff, which raises the patient’s level of trust and encourages commitment to care plans (Garcia-Jorda et al., 2022). Along with this, effective communication will help make decisions for patient well-being. To know about patients’ recent conditions, healthcare staff must communicate with previous healthcare agencies to avoid collecting information inaccurately. Mrs. Snyder is suffering from stress and depression due to the high cost of treatment, so she needs effective collaboration and moral support to get rid of depression and anxiety. Effective communication reduces the chances of adverse events and mortality rates within the organization (Yazdinejad et al., 2020). 

Potential Effects of Ineffective Communications

Ineffective communication can cause serious consequences like quick, timely, and appropriate treatment delays. In case of any emergency, lack of ineffective communication can cause serious issues like patients will not get immediate treatment as healthcare staff did not have accurate information about patients. Ineffective communication can also lead to serious health disparities, which can cause death (Raeisi et al., 2019). Ineffective communication can negatively affect patient treatment outcomes and quality of care. 

Due to ineffective communication, patient cost of treatment can also be increased because of an absence of communication. As information is not provided appropriately to destination healthcare providers, patients get repeated tests, which can cause unnecessary expenses. Ineffective communication can also cause a lack of trust and patient satisfaction toward healthcare professionals. Due to a lack of satisfaction, patient care quality will also be affected (Raeisi et al., 2019). 

Barriers to the Transfer of Accurate Patient Information

An effective transitional care plan depends on transferring proper information to destination hospitals. The lack of sufficient staff may be one of the actual obstacles to sharing accurate information. During the transitioning period, a nurse or any other staff member will be unable to perform their jobs effectively due to excessive burdens and responsibilities. Therefore, it could miscommunicate information (Ilardo & Speciale, 2020). 

Uncompleted medical histories are another barrier, such as missing test results and other diagnosis documents, which may cause miscommunication. Due to incomplete medical records, time will be wasted if testing and other medical procedures must be redone.

Due to the possibility that insurance may not always pay for repeated testing, it may also place an economic burden on the patient and their family. Sometimes, the transitional healthcare provider may need more room to accommodate patients’ needs. Planning and information sharing are essential as a result. Therefore, one of the main potential obstacles that can result in the patient’s health state getting worse is a lack of effective teamwork and clear communication (Cullati et al., 2019).

Lack of knowledge about Electronic Health Records (EHR) technology is another potential barrier that can cause miscommunication. Due to this, accurate patient information will not be transferred to the destination hospital because of a lack of training in healthcare professionals regarding EHR technology, which can cause serious issues (Tsai et al., 2020). 

Strategy to Establish Absolute Understanding of Continued Care

Various strategies can help to provide patients with effective care treatment. Healthcare professionals must get proper and correct information about patients to avoid issues. So best practice strategy is to develop appropriate planning so that accurate information will be transferred to the destination hospitals. By doing so, patients do not have to face financial burdens, and the mortality rates can also be avoided. By proper planning, Mrs. Snyder’s full medical history will be transferred to the destination hospitals to prevent serious complications. Along with this, destination healthcare providers will also get a medication reconciliation list of Mrs. Snyder which will avoid adverse events due to the wrong medication (Glans et al., 2020). 

Another strategy is to conduct follow-up sessions with which healthcare providers will understand Mrs. Snyder’s perspective regarding the destination medical center. It is important to develop a collaborative strategic approach to avoid communication gaps and get to know about patients’ concerns easily. Along with this, organizations must focus on providing complete discharge instructions to the patient and other destination healthcare providers, like which medicine Mrs. Snyder is allergic to, and she has to adopt a self-management plan of care to live a healthy lifestyle. The transitional care plan will be successful if healthcare organizations focus on these strategies (Spencer & Singh Punia, 2020). 

Conclusion

The transitional care plan is important when transferring patients from one healthcare sector to another. It will help to transfer the complete patient medical history to other healthcare sectors so that serious complications and mortality rates can be avoided. In the case of Mrs. Snyder, this plan will help her to get the best care treatment and learn about self-management techniques to live a healthy lifestyle and get rid of diabetes-related serious consequences. Along with this, proper planning and follow-up strategies will also help to improve the quality of care treatment for patients. 

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

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