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Running head: TRANSITIONAL CARE PLAN 1
Transitional Care Plan
Name
Institution Affiliation
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TRANSITIONAL CARE PLAN 2
Transitional Care Plan
Patient Rebecca Snyder along with relatives and social laborer, was interviewed for the
admitting demographics. Rebecca Snyder is a woman of 56 years of age with a long term obese
Orthodox. Snyder has a past medical history of poorly controlled diabetes, hypertension,
hypercholesterolemia, anxiety, and obesity. She admits to the ED with protests of hyperglycemia
more than 230 for more than ten days, frequent urination, mild abdominal discomfort, malaise,
and dyspnea on exertion. As per the medical records, on date 5th August 2019, the patient was
determined to have Ovarian Cancer, and she was under medication for the condition. Therefore,
the paper aims to explore medical information and outline the nursing care plan for Rebecca
Snyder.
Snyder’s Case on Transitional Care Plan
Healthcare is advancing, and there has been a push to give care in the community rather
than protracted hospitalizations. These advances require a safe, effective, and ideal care plan for
the patient and the family. Naylor et al. (2017) state that transitional care alludes to the
coordination and congruity of medical care while developing a patient starting with one
healthcare setting, then onto the next healthcare setting or the patient's home. Transitional care
includes the careful coordination and planning of the multidisciplinary group to guarantee a
smooth change for the patient and the family (DelBaccio et al., 2015). Drawing in and teaching
the patient and family concerning the patient's complex healthcare needs and the requirement for
transitional care require a multidisciplinary team to keep away from disarray and superfluous
readmissions.
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TRANSITIONAL CARE PLAN 3
Key Elements and Information Needed for Transitional Care
The Joint Commission(2015) recognizes the seven basics of the Transitional Care Model
(TCM) as essential in ensuring a safe transition from a healthcare facility to another. The
following are the seven approaches to enhance Snyder’s effective transitional care plan;
1. Leadership support: With the hospital, home health agencies senior leaderships, and
national policymakers becoming more conversant with the challenge of the transition, they have
become invested in finding solutions and the initiatives to be valuable in reducing readmissions
and achieving other favorable outcomes.
2. Multidisciplinary collaboration: For safe transition, the multidisciplinary arrangement
needs to commence the care, not just before the transition, and it also consists of involvement by
the patient and family/friend caregivers, as well as healthcare professionals, and more
importantly, the social workers(SW) and nurse case managers(CM) (Labson, 2015).
3. Early identification of patients at risk: High-risk patients for readmission are known by
aspects such as the number of prior admissions, high emergency department(ED) utilizers, health
literacy, social determinants of health (SDOH), confidence in self-care, complexity of the
medical condition, and discharge condition (Labson, 2015).
4. Transitional planning: Planning for care transition is more than the patient’s discharge
instructions; it involves effective coordination with all of the appropriate care providers
necessary to ensure that the patient is effectively transitioned home.
5. Medication management: Providing a medication list as part of a care transition is only
a start; educating patients and assessing their understanding of new medications will improve
adherence.
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TRANSITIONAL CARE PLAN 4
6. Patient and family action/engagement: Efforts to engage the patient and family are
ongoing education processes with the case management transition team. The team encourages
patient/family engagement, shared decision making and provides understandable instructions.
7.Transfer of information: Successful transfer of information between organizations,
patients, and referral sources is continuous by using remote monitoring and electronic health
records.
Mrs. Snyder's multidisciplinary team will need to collaborate care with her and the family
to make her end of life care known to the hospice facility. Encouraging patient and family
engagement will provide a clear understanding of Mrs. Snyder's and her family's wishes to
promote continuity of care and a smooth transition of care from one facility to another. Also
needed is the patient's medication list, plan of care, family and church contact, and advance
directives to prevent a breakdown in care. These multidisciplinary interventions will ensure that
Mrs. Snyder positively transitions to the hospice facility for continued care.
Importance of each Key Element
1. With senior leadership support, this empowers the multidisciplinary team to
continually evaluate and improve patient transition processes.
2. The multidisciplinary approach now extends beyond the care conference to how care
transitions are made; how care is planned and provided in the home; and how patients,
caregivers, and staff are involved and educated.
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TRANSITIONAL CARE PLAN 5
3. Early identification of patients/clients at risk and acquiring a better understanding that
assessing the risk of readmission is an essential first step toward prevention; evaluating and
understanding the patient's state of mind, goals, concerns, and health literacy is another crucial
step.
4. Planning for care transitions is more than planning a handoff; it is planning to ensure
continuous patient engagement, monitoring, and evaluation with a series of ongoing transitions
extending over the entire patient care period.
5. Compliance with medication regimens remains vital to optimal health outcomes, and
using tools to increase patient understanding, engagement, and patient-friendly medication lists,
are helping to improve adherence.
6. Patient and family action/engagement involves providers guiding patients toward
making their own decisions, instead of merely telling them what to do; once genuinely engaged
in their care, patients become physically, psychologically, and socially activated for the
betterment of their health.
7. Transfer of information using remote monitoring and electronic health records(EHR)
provides constant follow up with patients and offers effective handoffs and information transfer
for patients transitioning to other healthcare facilities or physicians (Labson, 2015).
Importance of Effective Communication
Engaging the patient and family and earning their trust will assist in effective
communication and smooth care transitions. Suppose the patient and family are made to feel
comfortable and included in their care. In that case, they will be more receptive to learning and
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TRANSITIONAL CARE PLAN 6
participate in question and answer sessions involving new medications, testing, procedures, or
transfers to other healthcare facilities. Patients need to be presented with healthcare options and
be made to feel they are an active participant in their care, instead of feeling they are being told
what needs to take place(Naylor et al., 2017).
Barriers to the Transfer of Accurate Patient Information
There are numerous barriers to care when transitioning patients, and the healthcare team
must begin discharge planning at admission to acknowledge those barriers and overcome any
obstacles before discharge. Many HH agencies do not have access to EHR and rely on hospitals
to electronically fax the patient’s discharge bundles. If this is overlooked at discharge, a patient’s
care can be delayed in the home due to the agency awaiting hospital orders and care
recommendations. Another concern of incomplete or delayed information transfer is the
likelihood of medication errors or a delay in receiving medications.
Strategies to Ensure Accurate Care
Discharge planning will begin promptly with Mrs. Snyder by having a family meeting
and giving the family choices to the furthest limit of life care in their favored hospice facility.
Offering decisions and permitting the patient and family official help in smooth progress. The
multidisciplinary group will use the Continuity Assessment Records and Evaluation (CARE)
item set, created by the Centers for Medicare and Medicaid Services (CMS), to give legitimate
adequate communication to finish a successful transfer. When a facility is chosen, it is the
healthcare hospice group that precisely encourages Mrs. Snyder's discharge prescription
rundown. The essential worry for Mrs. Snyder has torment control. Her agony should be tended
to and controlled with the right torment drug to give comfort and keep away from any necessary
transfers back to the clinic for torment control. In conclusion, the discharge outline needs settling
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TRANSITIONAL CARE PLAN 7
with Mrs. Snyder, her family, and the multidisciplinary group all in agreeance with the discharge
plan. When discharge planning is finished, discussions need to happen with the accepting facility
to ensure they can oblige Mrs. Snyder's social needs, recommended torment meds, and family
visits. When last care courses of action are set up and perceived by all healthcare suppliers, the
electronic transfer of discharge plans occurs, and a paper duplicate of the discharge is provided
with the emergency vehicle at the time of transfer.
Conclusion
This paper examines the significance of utilizing the Transitional Care Model to facilitate
safe, ideal, and collaborative discharge for patients being transferred to another healthcare
facility or home to utilize a home healthcare agency. This paper discussed the seven critical
components perceived by the Joint Commission for successful transitional care. The seven
critical components of transitional care were exploited by discussing Mrs. Snyder's case in this
evaluation. However, these key components can be applied to any patient case.
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TRANSITIONAL CARE PLAN 8
References
DelBoccio, S., Smith, D., Hicks, M., Lowe, P., Graves-Rust, J., Volland, J., Fryda, S., (2015).
Successes and challenges in patient care transition programming: One hospital's journey.
OJIN: The Online Journal of Issues in Nursing, 20(3).
https://doi.org/10.3912/OJIN.Vol20No03Man02
Labson, M. C. (2015). Adapting the joint commission’s seven foundations of safe and effective
transitions of care to home. Home Healthcare Now, 33(3), 142–146.
https://doi.org/10.1097/NHH.0000000000000195
Naylor, M., Berlinger, N. (2016). Transitional care: A priority for health care organizational
ethics nurses at the table. Nursing, Ethics, and Health Policy, Special Report, Hastings
Center Report, 46(5), 39–42.
https://doi.org/http://web.a.ebscohost.com.library.capella.edu/ehost/pdfviewer/pdfviewer?
vid=3&sid=ccf9a759-8710-4e8e-aab3-d5631bedee92%40sdc-v-sessmgr02
Naylor, M. D., Shaid, E. C., Carpenter, D., Gass, B., Levine, C., Li, J., Malley, A., McCauley, K.,
Nguyen, H. Q., Watson, H., Brock, J., Mittman, B., Jack, B., Mitchell, S., Callicoatte, B.,
Schall, J., & Williams, M. V. (2017). Components of comprehensive and useful
transitional care. Journal of the American Geriatrics Society, 65(6), 1119–1125.
https://doi.org/10.1111/jgs.14782
The Joint Commission. (, 2015). Transitions of care: Engaging patients and families. Quick
Safety: An Advisory on Safety & Quality Issues.
https://www.jointcommission.org/-/media/tjc/documents/newsletters/quick_safety_issue_
18_november_20151pdf.pdf
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TRANSITIONAL CARE PLAN 9
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