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Due to the rising hospital readmissions rates which are as a result of poor transitional care, it is important to develop a program that will make sure the existing problems facing transitional care are effectively taken care of and that in specialized nursing is enhanced to promote the provision of transitional care. At the present time, committee of health care has suggested various interventions which require to be adopted and implemented by the project manager to ensure transitional care is improved especially in regards to taking care of elderly patients. Some of the interventions that are great at decreasing the rates of patient readmission include assessment of the patient needs, patient education and medication reconciliation (Morrison, 2016). It is very important that once patients are discharged healthcare professionals should constantly communicate with them and their caregivers get effectively trained on how to handle various situations which are related to medical conditions that are very common (Zenno, 2018).

Due to the interventions that have been proposed, the main aim of the project is to address transitional care challenges by interpreting the duties of homebased services, the importance of caregiver support, partnerships within the community and the relevance of new transitional care personnel. To ensure the project is a success, the manager has developed a timeframe that indicates when the project should be completed, a practical budget, the manner in which resources will be distributed and the tools to be utilized while conducting the project.

The Project’s Time Frame

For the transitional care program to be endorsed, it requires a defined timeframe indicating how various roles will be achieved. Based on the project’s manager analysis, the planned timeframe that is meant to bring significant improvements in transitional care entails having six scheduled visits to healthcare facilities for a period of two years. Within those two years, there will be a close working relationship with healthcare providers, elderly patients, caregivers as well as other key stakeholders involved in transitional care. The first twenty-four weeks (six months) will entail utilizing an observation method to determine the current condition of transitional care in healthcare facilities. During this period, notes will be taken indicating how the healthcare facilities receive parents, how they are admitted in emergency departments, the interactions of nurses with elderly patients and coordination between the caregivers and healthcare professionals when patients are discharged.

The second six months will be utilized in evaluating nursing expertise in relation to transitional care. Extensive research indicates that using unspecialized nurses is a key challenge that affects the effective provision of healthcare services. In addition, past studies indicate that there is a huge difference in the manner in which masters-level nurses provide services and the manner in which nurses below the masters-level do it. Therefore, the second six months will be utilized in determining the level of education, training and experience among nurses who offer transitional care. Again, the observation method will be utilized to determine the differences between specialized and unspecialized nurses. This entails evaluating the manner in which they handle elderly patients, their coordination with healthcare providers and their coordination with caregivers (Hirschman, 2015).

The first twenty-four weeks (six months) of the second year will be utilized in making home visits to evaluate the level of expertise that caregivers have while taking care of patients after they are discharged from health care facilities. During this period, some of the activities that will be carried out include engaging with caregivers to determine their preparedness level, expertise and education and how effective they are able to decrease the hospital readmission rates. Again, the period will be utilized in determining the response of the patient to the care offered by the caregivers and how fast they recover from their various ailments after they are discharged.

The second twenty-four weeks of the second year will be utilized in combining the acquired results and getting back to sections which may have inadequate information to ensure the results are free from biases. The two-year (96 weeks) time frame set for the project will be adequate to make sure the current challenges facing transitional are effectively addressed.

Project’s budget

For the project to be successful and all the activities within it to be effectively conducted within the specified timeframe, a budget will be developed to make sure all activities are handled based on the allocated budget to ensure the complete costs are not more than the current working revenues. According to the manager of the project, a working a budget of $9,000 will be enough for the project. The following is a breakdown on how the $9,000 will be utilized.

1. Compensating employees ($4,000)- A team composed of ten members will be used to acquire data from patients, caregivers, nurses and healthcare providers. The team must be compensated through offering reasonable wages and incentives.

2. Contract services ($1,500) – Various health care personnel will be outsourced to be consulted about various issues in regards to the project. The care providers must be compensated through part-time wages whenever they are called upon to offer their services

3. Supplies ($1,500) – For the project’s activities to be effectively conducted, various supplies will be needed. Some of the supplies include consumables, office supplies, computer supplies etc.

4. Travel expenses ($1,000) – For the project’s activities to be effectively conducted, extensive travelling is required therefore with $1,000, all travelling expenses including air travel will be catered for.

5. Overhead expenses (1,000) – Finally, $1,000 will be allocated to catering for all the overhead costs to ensure all administrative and daily operations costs are effectively taken care of.

Project tools/resources

To ensure the project is entirely successful, various tools and resources must be utilized to make sure key stakeholders are involved in the project. Some of the major tools and resources include materials of patients, hospital models and important individuals that will be engaged in managing the project.

Patient/Family Resources

i. Family discharge planning checklist

This is a tool that ha various questions that should be answered by both the caregiver and the patient before discharge.

ii. Next Step in Care

This is a website that offers guides and checklist to caregivers and healthcare providers to ensure transitional care is improved (Naylor, 2018).

iii. Patient PASS

This is a document that has all the requirements of a patient to ensure he/she safely transitions from a healthcare facility to his/her home.

iv. Personal health record

This refers to a record which indicates all the activities patients should perform to better manage their conditions.

v. Patient discharge planning checklist

This is a tool which has various questions patients should answer before being discharged. Some of the questions include: where the patient will get care after discharge, the problems the patient should look out for and what to do about them, whether medical equipment is required and how bandages or shots should be performed. Caregiver’s are also supposed to answer various questions relating to options for continued care (Toles, 2016).

The mentioned resources/tools will be very important in ensuring transitional care is improved through engaging all the key stakeholders and using key documentation in the transitional process to make sure patients safely transition from hospitals to their homes. The resources/tools are also useful in ensuring caregivers have adequate knowledge on how to manage patients in order to decrease the rate of hospital readmissions.

References

Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., & Naylor, M. D. (2015). Continuity of care: The transitional care model. OJIN: The Online Journal of Issues in Nursing, 20(3), 1.

Morrison, J., Palumbo, M. V., & Rambur, B. (2016). Reducing preventable hospitalizations with two models of transitional care. Journal of Nursing Scholarship, 48(3), 322-329.

Zenno, A., & Gordner, C. (2018). Implementation of a Transitional Care Program to Educate and Empower Pediatric Patients with Diabetes Mellitus.

Toles, M., Colón-Emeric, C., Naylor, M. D., Barroso, J., & Anderson, R. A. (2016). Transitional care in skilled nursing facilities: a multiple case study. BMC health services research, 16(1), 186.

Naylor, M. D., Shaid, E. C., McCauley, K., Carpenter, D., Gass, B., Levine, C., ... & Williams, M. V. (2018). COMPONENTS OF COMPREHENSIVE AND EFFECTIVE TRANSITIONAL CARE. Innovation in Aging, 2(Suppl 1), 202.