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Transitional Care Plan

Learner’s Name

Capella University

NURS-FPX6610: Introduction to Care Coordination

Instructor Name

September 1, 2019

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Transitional Care Plan

Transition care plans play an important role in facilitating the effective transition of

patients from one care setting to another. They are critical to the efficient and timely execution of

a broad range of transitional care services, which help promote the utmost safety and quality of

care for patients during transition. This paper will use the simulated case of Mrs. Snyder to focus

on key elements of transitional care, the significance of effective communication in transitional

care, the barriers that inhibit the transfer of information, and strategies to facilitate accurate

patient information transfer. Mrs. Snyder suffers from a terminal illness and has been scheduled

for a transition from a hospital to a hospice facility specializing in end-of-life care.

Key Elements and Information Needed for Ensuring High-Quality Transitional Care

The key elements needed for facilitating qualitative transitional care are as follows:

• Medication reconciliation: It refers to the process of comparing a patient’s prescribed course

of medication against the medication that he/she has been taking until the point of transition

(World Health Care Organization, 2016).

• Communication of patient information to the destination care provider: It is important to

ensure that the destination care provider and the patient are provided with accurate, reliable,

and highly relevant patient information (Li et al., 2014).

• Patient education: Case managers should ensure that patients are duly educated on various

facets of health care such as self-responsibility toward care, better lifestyle choices, and

continuity of care (Naylor et al., 2017). For instance, instructing Mrs. Snyder to opt for

hospice care with continuous chemotherapy accompanied by intravenous steroids and

antiemetics is important to ensure that the transition of care is effective and improves her

outcomes.

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• Individualized transitional care plan: It refers to an individualized care plan that includes

determination of the appropriate time for the patient to be discharged, the referral

arrangement to the destination care setting (World Health Care Organization, 2016), and

formulation of the patient’s needs, goals, treatment, medication, rehabilitation, and social

support (Li et al., 2014).

• Community support: Access to adequate community resources such as transportation

facilities, social support, health literacy, and outpatient care are critical to avoiding adverse

medical events such as hospital readmissions and deaths (Li et al., 2014).

• Ensuring continuity of care: This refers to the comprehensive implementation of the

transitional care plan. Case managers must ensure timely access of appropriate and

qualitative health- and community-based services, ensure timely exchange of information

between health care providers, and facilitate continuous access to the various sources of

health care (Naylor et al., 2017).

The information required to effectively transition Mrs. Snyder includes test results, a

discharge medications list, a course of hospitalization, patient counseling records, follow-up

plans (Li et al., 2014), social security and insurance information, medical history, advanced

safety risk measures, and detailed treatment and medication records for comorbid chronic

conditions.

Importance of Key Elements of a Transitional Care Plan

The significance of key elements of a transitional care plan is as follows:

• Medication reconciliation plays a crucial role in minimizing the occurrence of adverse drug

events and avoiding hospital readmissions (World Health Organization, 2016).

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• The transfer of adequate, reliable, and accurate patient information to the destination care

provider is crucial to avoiding critical medical errors, minimizing the repetition of

medication procedures, and reducing health care costs. A study by Solet, Norvell, Rutan, and

Frankel (2005) estimates that 80% of critical medical errors arise from miscommunication

between health care providers during information transfer (as cited in Li et al., 2014)

• Patient education is important for ensuring that a patient adheres to discharge instructions

and medication, follows up with a care provider regularly (Mansukhani et al., 2015),

chooses the best course of care, and adopts a healthy lifestyle. A review study by Hibbard

and Greene (2013) highlights evidence-based studies that show direct links between patient

activation and healthy behavior, improved health care outcomes, and enhanced care

experiences (as cited in Li et al., 2014).

• The development of a comprehensive transition care plan is critical for the provision of

efficient and qualitative care. It helps set into motion the timely discharge of patients and

their transition to the most appropriate treatment and care setting.

• The importance of community resources can be substantiated by the fact that their

insufficiency has been the cause of hospital readmissions. A study by Englander and

Kansagara (2012) found that 40%–50% of hospital readmissions arose from social problems

and poor access to community resources (as cited in Li et al., 2014).

• Ensuring continuity of care plays a critical role in fostering trust in the sending care

organization in the patient and the destination care provider (Naylor et al., 2017). A study by

the American Society of Health-System Pharmacists and American Pharmacists Association

(2013) found that the Medication REACH program (a program that offers uninsured patients

free medicines) at Einstein Medical Center has a significant impact on hospital readmission

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rates, with a 10.6% readmission rate for a cohort study group under the intervention and a

21.4% readmission rate for a control group not under the intervention. The findings from the

study serve as substantive proof for the positive impact of ensuring access to care continuity.

Potential Effects of Incomplete or Inaccurate Information on Care

A potential effect of transferring incomplete or inaccurate information is a delay in

treatment, which may result in adverse medical errors (Australian Commission on Safety and

Quality in Health Care, 2017). Inaccurate information may lead to wrongful treatment, which

may result in deterioration of health, or death in worse scenarios. A focused group study by

Allen et al. (2013), based on interviews with district nurses who dealt with older patients with

complex needs, concludes that poor information quality and untimely referrals result in treatment

delays and increased probability of adverse medical events (as cited in Australian Commission

on Safety and Quality in Health Care, 2017). Another potential effect of incomplete information

transfer is the increased likelihood for medication errors. In the absence of timely transfer of a

medication list from the hospital to the primary care settings, the general practitioner may fail to

consider changes in medication and may prescribe the wrong medication (Australian

Commission on Safety and Quality in Health Care, 2017).

Importance of Effective Communication

Effective communication is important to enable the transfer of relevant patient

information at the right time, which helps in facilitating informed, efficient care decisions by the

patient and destination care provider (Marder, 2018). Effective communication is critical in

forging a positive relationship between the patient and caregiver and, therefore, contributes in

increasing the patient’s trust level and adherence to care plans (Naylor et al., 2017).

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Potential Effects of Ineffective Communications

A potential effect of ineffective communication is the inability of health care

management to ensure the swift, timely, and efficient admission of patients to the destination

health care setting. Consider an emergency case in which, because of the lack of accurate

transfer indication, a patient is transferred to an unqualified health care setting and later

retransferred to a health care setting. The uncalled-for delay in admission may have serious

health repercussions, including death (Pourasghar et al., 2016).

Ineffective communication may also lead to excessive costs for the patient. The absence

of a standard communication mechanism in the transfer of patient information may result in the

destination caregiver repeating laboratory tests, resulting in undue expenses (Pourasghar et al.,

2016). Another potential effect of ineffective communication is the lack of trust or a sense of

uncertainty among patients toward care providers because of the absence of transparency in

communication and poor care coordination (Pourasghar et al., 2016).

Barriers to the Transfer of Accurate Patient Information

A potential barrier to the transfer of accurate information from one care provider to

another, be it from one level of care setting to another, is the unplanned and off-hour transfer of

patients. Consider the case of Mrs. Snyder, who is transferred from a hospital to a hospice care

facility; the transfer of patient information hinges on the availability of a clear plan for post

discharge care, the timing of the transition, and the post discharge destination of patient. The

availability of the plan is critical to facilitating the accurate, relevant, and reliable transfer of

patient information.

An actual barrier reported by several experts involved in the transfer of patients is the

absence of a dedicated person responsible for the admission of patients from the sending

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organization to the destination provider, which opens the chances of faulty information transfer

(Pourasghar et al., 2016). The lack of a dedicated person to handle Mrs. Snyder’s case may result

in the transfer of inadequate patient information or the mistaken transfer of another patient’s

information because of confusion in names.

A potential barrier to the accurate transfer of patient information is the absence of patient

information standards. The lack of a standard format for electronic health records, a standard

template for the information to be transferred, and a standard communication mechanism may be

a significant block to the transfer of accurate information.

Strategies to Ensure that the Destination Care Provider has an Accurate Understanding of

Continued Care

To ensure that the destination care provider has an accurate understanding of continued

care for Mrs. Snyder, the following strategies can be adopted in a sequence:

a) The development and execution of a discharge plan. A discharge plan is a personalized plan

that includes the determination of the appropriate time for a patient’s discharge and adequate

provision of the post discharge care required by a patient (Alper et al., 2019). The execution

of discharge plan will ensure that Mrs. Snyder’s information is transferred at the right time

and that the destination care provider has enough time and information to understand her

case and make adequate arrangements for continued care. A systematic review study by

Sheppered et al. (2010) found that discharge plans were associated with improved patient

satisfaction and small declines in patients’ length of stay and readmission rates (as cited in

Alper et al., 2019).

b) Once the discharge plan is developed, it is important to ensure that medication reconciliation

for Mrs. Snyder is performed before the discharge medication list is prepared. Medication

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reconciliation is highly critical to facilitate accuracy and completeness in the development of

the discharge medication list. The Joint Commission’s National Patient safety goals report

for 2015 found that discrepancies in the medication reconciliation process were associated

with medication errors, delay in the reception of medication, and higher rehospitalization

rates (as cited in Mansukhani et al., 2015). It is fair to say that medication reconciliation will

help facilitate the accurate transfer of Mrs. Snyder’s information, namely the discharge

medication list.

c) The case manager must ensure the development of an adequate discharge summary and its

successful transmission in a timely fashion. A discharge summary is critical to helping

clinicians from the receiving care organization form a holistic understanding of Mrs.

Snyder’s case instantly and, thus, contribute toward effective continuity of care. A

retrospective study by Hoyer et al. (2016) found that delay in the completion of discharge

summaries was associated with higher readmission rates in hospitals (as cited in Alper et al.,

2019). An effective mechanism to ensure that discharge summaries carry accurate

information is the use of standardized forms or templates (Mansukhani et al., 2015).

d) Lastly, it is important to ensure that Mrs. Snyder’s transfer records are accompanied by a

direct verbal exchange between the clinicians of the sending and receiving care providers. A

study by Jeffs et al. (2013) that was based on 31 interviews with clinicians involved in

transitional care found several clinicians advocating the exchange of verbal reports between

clinicians of the same level from the sending to the receiving organization.

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Conclusion

In this paper, the author has successfully highlighted the various elements of a

transitional care plan. The simulated case of Mrs. Snyder, advised to transition to end-of-life

hospice care, has been used as a reference to highlight the importance and functionality of the

various elements of a transitional care plan. The transfer of accurate, reliable, and relevant

patient information is critical to facilitating the effective transition of care. The author has

comprehensively discussed the importance of the effective communication of patient information

and the implications of ineffective communication mechanisms. Finally, by carrying out

intensive research, the author has managed to highlight several evidence-based strategies to

facilitate accurate and efficient transfer of patient information.

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References

Alper, E., O’Malley, T. A., & Greenwald, J. (2017, December 19). Hospital discharge and

readmission. https://uptodate.com/contents/hospital-discharge-and-readmission

Australian Commission on Safety and Quality in Health Care. (2017). Improving documentation

at transitions of care for complex patients.

https://www.safetyandquality.gov.au/sites/default/files/migrated/Rapid-review-

Improving-documentation-at-transitions-of-care-for-complex-patients.pdf

Jeffs, L., Lyons, R. F., Merkley, J., & Bell, C. M. (2013). Clinicians’ views on improving inter-

organizational care transitions. BMC Health Services Research, 13, 1–8.

https://doi.org/10.1186/1472-6963-13-289

Joint Commission International. (2018). Communicating clearly and effectively to patients: How

to overcome common communication challenges in health care [White paper].

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https://doi.org/10.3949/ccjm.81a.13106

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Marder, K. (2018, January 4). Saving lives: Effective healthcare communication empowers care

management. https://healthcatalyst.com/effective-healthcare-communication-care-

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management

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.,

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comprehensive and effective transitional care. Journal of the American Geriatrics

Society, 65(6), 1119–1125. http://doi.org/10.1111/jgs.14782

Pourasghar, F., Kavakebi, N., Tabrizi, J. S., & Mohammadi, A. (2016). Barriers to

communication and information exchange in patient transfer and its consequences.

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World Health Organization. (2016, December). Technical series on safer primary care.

https://who.int/patientsafety/topics/primary-care/technical_series/en/

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