Phase V .Apa Seven

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PHASE 1- PLANNING

A

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Introduction to the problem

Transitional nursing is Care provided to patients as they transit from one place to another.

Transition can be within the hospital setting, between care settings, within health states, and

between providers (Warchol et al., 2019). One of the transitions is discharge from the hospital to

home care. Patients are discharged from the hospital before they are completely cured but must be

well off to be able to recover at home. The patients are sent home with treatment packages and

sometimes may require frequent clinical visits by the nursing for care. The care plan during the

transition from hospital to home care includes the treatment goals, the health status of the patient,

treatment preferences and family as well as patient education. Coordination is crucial in this care.

In some cases, these discharge packages are not well elaborated. Miscommunication and

discontinued care may result in adverse effects on the patient. For example, the patient may

experience delayed care, unnecessary clinical visits, and stress to the patient or family, and poor

health outcomes.

Problem statement

The transition of the hospital to home care is done to enable the client to recover at home.

Healthcare professionals discharge clients with strict instructions for the client to continue with

care and recover fast. Due to poor communication and nursing care at home, many patients face

readmission. Readmission is defined as the return to hospitalization within 30 days of discharge

from the same condition. Readmission is among the costliest cases in the hospital setting to

manage. Hospitals incur huge costs in managing readmission. The federal government is also

affected. The US spends $17.4 billion on readmission costs. Hospitals readmit 20% of patients

enrolled in Medicare within 30 days upon discharge and 34% of the clients within 90 days of

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discharge. Unwanted and unnecessary health care costs amount to $765 billion yearly with

preventable admission accounting for $17 billion for Medicare (Warchol et al., 2020). Causes of

readmission are varied. Poor resolution of the original problem of the patient is a major cause of

readmission. The healthcare provided by professionals just relieves the pain and not the actual

problem. In such a case it is likely to reoccur. Discharge of patients too early may be a cause of

readmission. The patient is discharged before being stable enough to recover from home. In other

cases, inadequate care after discharge may make the condition worse. The nurse has a critical role

to play in the provision of care at such transition (Rezapour-Nasrabad, 2018).

Significance of the study

The significance of this study is to inform nurses of the gaps within the hospital-home

transition care and informing the necessary course of action to prevent readmission of clients. The

study will identify the major problems nursing practitioners face in transition care. Transition care

costs health facilities billions of dollars which could be avoided with proper intervention. Proper

communication and collaboration between health care providers post and Pre discharge can

provide coordinated care for better health outcomes. Adequate care post disgrace will reduce the

rate of readmission. The study will be significant to clinics and other healthcare centers. The

billions of dollars that government spends on readmission could be channeled to other treatment

avenues. Nurses and doctors can work in harmony and coordinate care during the transition.

Through education of patients, families, effective care is possible and can help to reduce

readmission.

Purpose of the study

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The purpose of this study is to investigate methods nurses use to reduce the readmission of

patients after discharge. Most patients undergo a state of depression together with their kin because

of the reoccurrence of diseases that could be avoided before discharge. Going back to the hospital

makes it costly for instance to people who are not enrolled in health insurance cover (Upadhyay et

al., 2019). In the US, the costs families incur during readmission dent their economic stability,

resulting in them using coping strategies to mitigate the financial challenges. The study will assess

the major methods that can be used by clinicians to prevent readmission. Treatment of the main

condition rather than the symptoms as well as proper communication between health professionals

during discharge is essential in promoting patient recovery. In addition, nurses can take an active

role in improving care for patients in a transition phase. Making the necessary interventions can

reduce the rates of readmission in the hospital setting. The hospital should be a temporary place for

the treatment of patients before discharge within the shortest time possible. Long hospital stay is

associated with poor health outcomes and increased costs.

Research Questions

The study wishes to find key issues surrounding nursing care during the transition. The

nurse has a critical role in the management of students to minimize readmission rates. Some of

these research questions to be addressed include;

1. What strategies can hospitals put in place to prevent readmission of patients?

2. What is the role of nurses in the transition care of patients?

3. What is the role of hospital management in ensuring they reduce readmission costs?

4. What is the purpose of communication between professionals before the discharge of patients?

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Masters essentials aligned to the study

Nursing care is an essential component in patient management. Nursing skills acquired in

training can be well utilized to provide comprehensive and timely care to all patients. During

transition care, nurses' efforts ought to be recognized and acquired to assist patients to recover well

at home or any other transitory place or setting. Research gaps still exist that nurses can explore

and recommend necessary actions for continuous implementation in patient management. With the

proper application of nursing theories, nurses can develop philosophies that can go a long way in

changing patient care in hospitals and beyond. Developing a research problem statement should be

the pursuit of any nurse who wishes to contribute immensely in the field of medicine.

In conclusion, nurses and healthcare are synonymous. To achieve adequate patient

management, the efforts and contributions of nurses should be the core element in the development

of treatment measures for clients. Transition care, for instance, requires the input of all healthcare

professionals and adequate planning as well as communication and elaboration of the plans to

achieve the goals. Research can contribute immensely to the development of adequate care plans

for patients and their families in transition care (De Regge et al., 2017). Nursing care not only

seeks to achieve physical wellbeing but also the emotional well-being of the client and the family

in times of distress.

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References

De Regge, M., De Pourcq, K., Meijboom, B., Trybou, J., Mortier, E., & Eeckloo, K. (2017). The

role of hospitals in bridging the care continuum: a systematic review of coordination of

care and follow-up for adults with chronic conditions. BMC Health Services Research,

17(1), 1-24.

Rezapour-Nasrabad, R. (2018). Transitional care model: managing the experience of hospital at

home. Electronic Journal of General Medicine, 15(5).

Upadhyay, S., Stephenson, A. L., & Smith, D. G. (2019). Readmission rates and their impact on

hospital financial performance: a study of Washington hospitals. INQUIRY: The Journal of

Health Care Organization, Provision, and Financing, 56, 0046958019860386.

Warchol, S. J., Monestime, J. P., Mayer, R. W., & Chien, W. W. (2019). Strategies to reduce

hospital readmission rates in a non-Medicaid-expansion state. Perspectives in health

information management, 16(Summer).