Nursing Research Discussion board "Research Project"

Florida National University

Planning Stage-1 of a Research Project

Many older adults suffer from multi-morbidity of various chronic conditions. These adults are hospitalized over a period of time before being released into the transition care model. However, in the transition care model most of these adults receive poor continuity of care which has resulted to negative outcomes for this patients. This is the problem being discussed in this research paper. There are numerous problems which have resulted to the poor continuity of care among these patients including inadequate communication and lack of follow ups or monitoring. The problem is significant to nursing for it has resulted in a decline in the quality of care being provided in health care facilities. The purpose of the research is to identify the problem and come up with the best measures for dealing with the issue. Research questions are to be directed towards patients, nurses and clinicians in these settings. These questions include reasons for the poor continuity of care and what can be done to change the situation. The essential of masters that are aligned to this problem include administrative and systems leadership and quality enhancement and safety.

Background

Continuity of care is a necessity for older patients suffering from multiple chronic conditions. Chronic conditions are the most common types of illnesses affecting Medicare beneficiaries with 37% of the 20 million having five or more chronic illnesses (Teno et al., 2018). These group of patients have difficulties in managing their healthcare due to certain factors including functional shortfalls and social obstacles. Consequently, there is an increase in the amount of acute illnesses among these group of patients hence higher rates hospitalizations and emergency encounters with clinicians. Studies that have been done reveal undesirable results among older patients who shift to post- acute settings following hospitalization. The study revealed a high percentage of re-hospitalization rates which was at 36% within a period of 30 days (Teno et al., 2018). While some of the re-hospitalization cases were unavoidable and necessary, a significant amount were preventable if continuous care was offered to this patients. There has been an increased burden on the side of patients who incur high costs which makes this research paper necessary.

Introduction to the Problem

The problem being researched is undesirable outcomes among elderly patients who move to post-acute settings following hospitalization. Most of the older patients having multiple chronic conditions have relapsed after leaving hospitals (Hirschman et al., 2015). This is attributed to the fact that there is poor continuity of care where physicians fail to do any form of follow up visits. Additionally, the family caregivers of these group of patients lack the necessary knowledge concerning the best and safe healthcare. As a result, most patients experience poor healthcare which results to auxiliary deterioration in the health status of patients. There are high numbers of hospitalizations that are preventable and visits to the emergency care units. The lack of continuity of care is a major problem that has caused a great burden among patients in terms of costs and suffering. Thus, there is need to research on the issue of poor continuity care and find possible measures that can be implemented to improve the quality of care being offered to patients.

Clear Identification of the Problem

There are numerous sets of problems that have been connected with the issue of negative results among older patients after transition to post-acute settings. Lack of engaging the patient is a significant issue that results to poor continuity of care (Hirschman et al., 2015). There is minimal to inadequate communication between the clinicians and the patients thus no directive is given to the patients on how to take care of themselves. Equally, there is no teamwork among the team members handling the patients (Berman et al., 2016). This results to lack of follow up visits and monitoring of the patients thus decreased health status. In addition, the services being provided to these patients have gaps and the gaps increase as the patient moves from one health care setting to another. The electronic health records of patients are not being transferred and shared with other professionals handing a particular case which causes the gaps. Thus, the above problems are the reasons why there is increased poor continuity of care among older patients who transition to post-acute settings.

Significance of the Problem to Nursing

Poor continuity of care has resulted to poor quality of care being provided to patients with multiple chronic conditions. This problem is of importance to the nursing professional to enable changes and implementation of strategies to improve on the outcome of patients in the transition care model. The most important thing is to enhance the outcomes of patients by enabling the understanding of the health goals of any patient (Berman et al., 2016). This will enable both clinicians and caregivers to design a streamlined plan that is patient-centered that can be used at homes and in rehabilitation facilities. Further, identifying this problem will help in decreasing the costs among the chronically ill and vulnerable patients through development of better health systems (Berman et al., 2016). This will increase satisfaction among both the staff and patients, increase loyalty and trust. Poor continuity of care has also caused numerous conflicts among clinicians with blames being directed at each other. If the problem is dealt with there will be reduced conflicts and thus promote a good working environment among health care professionals.

Purpose of the Research

The purpose of this research is to discuss in detail the problem of negative results experienced by adults in the transition care model. This is due to poor continuity of care that results from some categories of problems in the health care system. After identifying the problem, different recommendations can be made and implemented to improve the quality of care being offered to older patients. Promotion of the best standard continuity of care is the main objective of this research (Klarare et al., 2017). There is need to reduce breakdowns for patients who are in the transition care process. This means that physicians have to make home visits, maintain constant communication with their patients and collaborate with others in offering the best care. Promotion of self-management is also an important objectives of this research. This involves adequate monitoring and prompt response to any form of worsening symptoms. Additionally, a collaborative approach in transition care facilities is targeted by this research. This will allow nurses, social workers, pharmacists and family caregivers to share information about the patient therefore improved quality of care.

Research Questions

During any form of research it is important to formulate the most appropriate questions for asking the participants of the research to come up with the most accurate findings. During this research, the questions will be designed for three groups of participants including nurses, doctors and patients in the transition care model. The questions to be directed to the patients include how they can rate the quality of continuity care being provided during the transition care model. Further, they can be asked which areas need to be improved in order to improve the care being offered to them. For the nurses, the questions directed to them include why there is poor continuity of care following hospitalization. Another important question is if the reasons leading to poor continuity of care can be resolved and through which measures. It is also crucial to engage physicians and ask them why they fail to recognize problems as soon as it occurs and why there is inadequate monitoring of patients. Thus, these set of questions are accurate and appropriate for the research problem at hand.

Master’s Essentials That Align with the Topic

Organizational and systems leadership and quality improvement and safety are the Master’s essentials that align with the problem of negative outcomes among older patients who move to post-acute settings. Organizational and systems leadership incorporates all aspects of care including providing care and serving needs of the patients (Hicks & Rosenberg, 2016). Graduates of these level must demonstrate skills in effective collaboration and communication among different teams. This will enable proper delegation of roles, an integrated care system and thus increased quality of care. Alternatively, quality enhancement and safety is another essential of masters which aligns to the topic being researched. In this case, the program offered enables graduates to offer evidence-based care plans to patients which incorporate quality and safety processes. The graduates have skills required in analyzing and assessing adequate measures for improved quality of care. Thus, these two master’s essential are the most aligned to this research project.

Conclusion

In conclusion, undesirable results among older patients who transition to post-acute care setting is a great problem which is being discussed in this research paper. This is attributed to poor continuity of care in the transition care model. There are many reasons that have resulted to this problem as discussed. The problem is significant to nursing due to the decline in quality of care offered to patients. The purpose of the research is to identify the problem and find solutions to it in order to improve the quality of life among the elderly. This research targets both health care providers and patients and the questions will be directed to both groups. The research questions are well thought through and designed to give a clear and better understanding of the research project. Administrative and coordination leadership and quality enhancement and safety are the master’s essential that are aligned to this research problem. Thus, undesirable outcomes among older patients in the transition care model is a problem that needs research in relation to transitional nursing.

References

Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb's Fundamentals of Nursing: Concepts, process and practice. Boston, MA: Pearson.

Hicks, F. D., & Rosenberg, L. (2016). Enacting a vision for a master's entry clinical nurse leader program: rethinking nursing education. Journal of Professional Nursing, 32(1), 41-47.

Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2015). Continuity of care: The transitional care model. Online J Issues Nurs, 20(3).

Klarare, A., Rasmussen, B. H., Fossum, B., Fürst, C. J., Hansson, J., & Hagelin, C. L. (2017). Experiences of security and continuity of care: Patients' and families' narratives about the work of specialized palliative home care teams. Palliative & supportive care, 15(2), 181-189.

Teno, J. M., Gozalo, P., Trivedi, A. N., Bunker, J., Lima, J., Ogarek, J., & Mor, V. (2018). Site of death, place of care, and health care transitions among US Medicare beneficiaries, 2000-2015. Jama, 320(3), 264-271.