NURS FPX 6610 Assessment 3 Transitional Care Plan

Name

Capella university

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name

Date

Transitional Care Plan

Transitional care is an essential aspect of ensuring patient safety and quality healthcare. Its primary objective is to facilitate a seamless transition for patients between different phases of treatment, minimizing complications and improving overall health outcomes. This approach is particularly significant for individuals with chronic conditions who require continuous monitoring to prevent adverse effects. This document presents a transitional care plan for Mrs. Snyder, a 56-year-old patient with diabetes who has been admitted to Villa Hospital due to an infected toe. The discussion outlines the key elements of her care, identifies communication barriers, and proposes strategies to enhance the effectiveness of transitional care (Korytkowski et al., 2022).

Key Elements and Required Information for Quality Treatment

Effective transitional care involves strict adherence to guidelines that ensure optimal patient outcomes. The accurate diagnosis of the patient’s condition is crucial to prevent complications and provide appropriate treatment (Watts et al., 2020). For Mrs. Snyder, maintaining comprehensive medical records, conducting medication reconciliation, providing emergency care details, and considering patient feedback are essential components of quality care. Her medical history offers insights into potential co-existing conditions, such as hypertension or depression, which can influence her treatment plan (Chen et al., 2018).

Medication reconciliation is a key factor in ensuring that the prescribed medications align with her treatment goals, reducing the risk of adverse drug interactions (Fernandes et al., 2020). Additionally, emergency directives, including advance care planning, address her healthcare preferences and cultural considerations, fostering a patient-centered approach (Dowling et al., 2020). The availability of community resources, such as mobility assistance, social support, and outpatient care services, further contributes to her recovery and overall well-being (Yue et al., 2019).

Insight into Patient Needs and Communication Challenges

A well-structured transitional care plan must consider the patient’s needs, including relevant medical test results, prescribed medications, and details of prior hospitalizations. Addressing communication barriers is equally important, as miscommunication can lead to treatment delays, medication errors, and increased healthcare costs (Raeisi et al., 2019). Ensuring that healthcare professionals are trained in effective collaboration and electronic health record (EHR) utilization can help mitigate these risks (Tsai et al., 2020).

Strategies for Enhancing Transitional Care

A collaborative approach is essential in ensuring a smooth transition from hospital care to home or outpatient services. Proper planning and coordination allow for seamless information exchange, including medication reconciliation lists and discharge instructions, which are crucial for effective patient management (Glans et al., 2020). Follow-up sessions enable healthcare providers to evaluate the success of the care plan, identify gaps, and make necessary improvements. Additionally, educating Mrs. Snyder on self-care strategies, such as maintaining a healthy diet and engaging in regular physical activity, can significantly enhance her long-term well-being (Spencer & Singh Punia, 2020).

Summary Table of Transitional Care Plan

Heading	Details	References
Key Elements	Comprehensive medical records, medication reconciliation, patient feedback, and emergency directives are crucial.	Chen et al. (2018), Fernandes et al. (2020), Dowling et al. (2020)
Communication	Effective communication with healthcare teams minimizes treatment errors, delays, and patient dissatisfaction.	Garcia-Jorda et al. (2022), Yazdinejad et al. (2020)
Challenges	Incomplete records, inefficiencies in EHR systems, and inadequate staff training hinder care continuity.	Cullati et al. (2019), Tsai et al. (2020)

Conclusion

Transitional care plays a critical role in ensuring that patients like Mrs. Snyder receive consistent and high-quality treatment. By addressing communication barriers, fostering teamwork among healthcare providers, and prioritizing patient education, healthcare systems can significantly reduce complications and improve patient satisfaction. Implementing these strategies enhances individual health outcomes while also contributing to the overall efficiency and effectiveness of healthcare delivery.

References

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

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

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

NURS FPX 6610 Assessment 3 Transitional Care Plan

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

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

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

NURS FPX 6610 Assessment 3 Transitional Care Plan

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