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Introduction

Following the increasing rate of hospital readmissions resulting from poor transitional care, it is essential to implement a program that will ensure the current challenges facing transitional care are addressed, and that there is an increase in specialized nursing to help foster the provision of transitional care. Currently, the health care committee has proposed a number of interventions that need to be implemented by the project manager to see the improvement of transition care, especially in relation to dealing with elderly patients (Morphet et. al., 2014). Some of these interventions have been proven to result in the reduction of patient readmission rates. Among them include; patient needs assessment, patient education, medication reconciliation, timely outpatient appointment as well as the provision of telephone follow-up services (Morphet et. al., 2014).

It is essential that once patients are discharged from hospitals, they continue receiving enhanced communication, medication safety and that their caregivers receive advanced care planning and training on how to best manage the associated common medical conditions (Ortiz, 2019). Following the currently proposed interventions, the project aims to target the challenges on transition care by defining the role of home-based services, the significance in caregiver support, community partnerships and the importance of new transitional care personnel (Ortiz, 2019). The project manager has gone as far as proposing the time frame that will help see the realization of the effects of the project, a practical budget, as well as the resources and tools that will be used.

The Time Frame of the Project

The enactment of the transitional care program includes the creation of a well-defined timeline on how the different roles will be attained. Following the evaluations by the project manager, the planned timeline it will take to achieve concrete improvements includes having six scheduled visits to the hospitals for two years. The two-year time frame also includes; a close working relationship with elderly patients, health care providers and patient caregivers, all of them being key stakeholders in the transitional care process. The first six months of the proposed time frame will include the use of the observation method to ascertain the current state of transitional care in the hospitals. In this time frame, notes will be taken on how the patients are received in the hospitals, their admission to the emergency departments, the communication and coordination of the nurses when dealing with the elderly patients and the level of interaction between the caregivers and the health care providers in the event that the patients are released from hospitals.

The second half of the first year will be solely used to ascertain the level of nursing expertise in regards to transitional care. Past studies and the Masters' Essentials have ascertained that the use of unspecialized nurses remains to be one of the key challenges facing the provision of health care services. Additionally, previous observations and studies have established that there exists a significant difference in the provision of services given by masters-level nurses and those below the master’s level unit. Hence, the six-month-time-frame will be used to interact with the nurses providing transitional care, to determine their level of education and training as well as their experience when it comes to the provision of transitional care. The observation method will be used to observe the differences in the provision of services by both the specialized and unspecialized nurses.

The following six months of the second year will be used to make visits to the patient homes to determine the level of expertise held by the caregivers in relation to caring for the patients as soon as they are discharged from the hospitals. The key activities in this allocated time will involve holding conversations and interviews with the caregivers to ascertain their level of preparedness, education, and expertise in relation to taking care of the patients as a means to reduce the high rates of hospital readmissions. The time frame will also be used to observe how the patients respond to the care provided by their caregivers, their level of comfort and how fast they get back to their health as soon as they are discharged.

The last six months of the allocated time-frame will be used to consolidate the different results collected and to revisit areas with inadequate information. This is meant to eliminate any existing biases or inconsistencies in the results. Therefore, the allocated two-year time-frame for the project will be adequate enough to ensure that all the existing challenges in transitional care are completely addressed.

Budget for the Project

For the proposed activities to be accomplished in the allocated time, a budget will be put in place to ensure that all the activities are tackled within the proposed budget and that the total costs do not exceed the existing working revenues. The project manager has proposed a working budget of $9000. Below are the key expenses that will be incurred throughout the project;

1. $4000 for employee compensation – this includes the collection of data from the patients, health care providers, and the caregivers. It involves working with a team of about ten members and all will have to be compensated through the provision of wages as well as other benefits and incentives.

2. $1500 for contract services -This will be used in frequent outsourcing of different health care providers who will be compensated by means of part-time wages whenever their consultancy services are called upon.

3. $1000 for equipment and supplies - To facilitate the activities of the project a number of office equipment/supplies will be required, among them office supplies, postage, computer supplies, consumables, equipment repair and maintenance, office equipment and other supplies.

4. $1500 for travel-related expenses – For the related activities to be carried out, traveling is inevitable. Hence with $1000, the program manager is certain that all traveling expenses among them air travel, out of town expenses, daily parking, mileage expenses, and others will be well catered for.

5. $1000 for overhead and indirect costs - Lastly, there will be a $1000 allocation budget to ensure that all overhead expenses (indirect costs) are catered for, hence allowing for the project to cater to administrative as well as daily operations costs.

Resources/Tool Required for the Project

For the project to be successful, different resources and tools will be required to ensure all the stakeholders effectively take part in the project. The key resources include; patient/family materials, hospital models, and key personnel who will be involved in running the project.

Patient/Family Resources

a. Family discharge planning checklist

This is a tool that provides patients and caregivers with a list of questions that should be answered prior to the patient discharging process (Ortiz, 2019).

b. Next step in care

This is a website that provides the caregiver with resources and checklists to ensure caregivers are aware of how to take care of the patients before they are discharged from hospitals (Ortiz, 2019).

c. Patient PASS: A transition record

This is a document that includes patient requirements that will result in the safe transitions of the patients from the hospitals to their homes (Storm et. al., 2014).

d. Personal health record

This is a patient health record information that includes a checklist of all the activities that patients must do to manage their care better (Storm et. al., 2014).

e. Patient discharge planning checklist

This is a resource that includes a patient checklist where patients and caregivers respond to different questions before they are discharged from the hospitals. Some of these questions include; patient care needs, options for continued care, community-based resources and post-discharge care instructions (Storm et. al., 2014).

The above mentioned resources will play a key role in the project as they are targeted towards improving transitional care, by ensuring that all the involved stakeholders use key documentation in the transitional process, thus ensuring that the patients are in safe hands as soon as they discharged and that the caregivers are well educated on how to deal with the patients as a means to reduce instances of hospital readmissions.

References

Morphet, J., Griffiths, D. L., Innes, K., Crawford, K., Crow, S., & Williams, A. (2014). Shortfalls in residents’ transfer documentation: Challenges for emergency department staff. Australasian Emergency Nursing Journal, 17(3), 98-105.

Ortiz, M. R. (2019). Transitional Care: Nursing Knowledge and Policy Implications. Nursing science quarterly, 32(1), 73-77.

Storm, M., Siemsen, I. M., Laugaland, K., Dyrstad, D., & Aase, K. (2014). Quality in transitional care of the elderly: Key challenges and relevant improvement measures. International journal of integrated care, 14(2).

Ye, Z. J., Liu, M. L., Cai, R. Q., Zhong, M. X., Huang, H., Liang, M. Z., & Quan, X. M. (2016). Development of the Transitional Care Model for nursing care in Mainland China: A literature review. International journal of nursing sciences, 3(1), 113-130.