The results of the project
The main aim of the project was to determine the challenges that transitional care is facing, determine the effect of unspecialized care on transitional care and determine the importance of specialized care in improving transitional care. The study was able to determine five key challenges affecting the effective provision of transitional care to elderly patients. The challenges were as a result of the inability of the key stakeholders to effectively conduct their roles. The key stakeholders in transitional care include nurses, caregivers as well as the patients themselves.
Caregivers
Based on the study, a majority of the elderly patients did not have caregivers therefore making it difficult for the provision of transitional care. For those who had the caregivers, they indicated the caregivers played a crucial role in their transitional care. For instance, the caregivers offered adequate information to the nurses in regards to the patients’ health and also provided sufficient self-care during the process of admission and discharge. However, despite playing a great role in improving transitional care, the caregivers were supposed to consult healthcare personnel during the admission and discharge processes to be able to get more information about the condition, medications and surgical operations of a patient (Loeffler, 2016). The study determined that in a majority of the cases, caregivers were not effectively informed and were not also prepared for a patient’s discharge process. The caregivers often asked nurses whether the patients were completely ready to be discharged from the healthcare facility. Again, the study indicated that caregivers had high expectations from the nurses and healthcare providers. They expected them to sufficiently care for the patients until they fully recovered and were not ready to extend any form of transitional care to their patients.
The characteristics of patients
According to the study, it was clear that most patients upon admission suffered from different chronic ailments and other minor diagnoses such as fatigue and diarrhea. However, during admission, majority of the patients only indicated the main chronic conditions and did not present the symptoms linked to the minor diagnoses. Due to this, such patients were not prioritized during the process of admission and were required to wait at the emergency department. This led to the development of various symptoms such as anxiety, dizziness, confusion and walking problems when the patients were finally discharged. Again, the study determined that majority of the elderly patients acquired post-discharge infections. Based on the information gathered from interviewing patients, most of them were satisfied with the care offered to them during the process of hospitalization but were largely dissatisfied by the long waiting time during the process of admission (Albert, 206). In addition, most patients indicated that they were not prepared to get discharged which lead to confusion and anxiety in the transition process.
The level of expertise of healthcare professionals
Based on the study, it was evident that formal routines in relation to the admission and discharge processes were available. However, when the study was being conducted most of the physicians situated in the emergency department were interns who had very little knowledge regarding admission transitions. The study therefore identified a problem in their technical part because healthcare professionals with adequate experience and education should have been available to ensure clinical assessment is effectively conducted during the transition process. The study was also able to determine that the chief physician and the ward nurse were responsible for indicating the medication that a patient would take after discharge. In addition, the two were responsible for identifying those who were entirely ready to get discharged. In addition, the study identified that nurses had very little information in regards to a patient’s medical history during the discharge process and this affected the transition process.
Information exchange
Based on the study, information during the process of transition was transferred through three key methods which include electronic, written and oral. At the time of admission, caregivers were supposed to offer adequate information in relation to the patients’ condition and health. However, in a majority of the cases, the information provided was insufficient majorly because of missing tests and nursing reports and inadequate information about the current condition of the patients. Due to these insufficiencies, healthcare professionals hard a very difficult time in determining the accurate health condition of a particular patient. Again, they had a difficult time identifying the medical history of a patient and the right medication for the identified condition (Vedel, 2015). In addition, the study was able to determine that certain healthcare facilities did not have an entirely integrated computer system which resulted to various challenges in the transition process. However, nurses played a crucial role in coordinating the exchange of information during the process of transition whereby at discharge, the nurses constantly communicated with caregivers to offer more information about the health condition of a patient.
Lack of patient assessment
After arriving at healthcare facilities, a majority of the elderly patients presented morbidity and age-associated impairments. The patients spent a lot of time in the emergency departments before they could be evaluated by physicians. This lead to frustrations and confusion among nurses who were taking care of the patients (Orvik, 2016). Again it led to delayed patient evaluation and introduced complications to the process of transferring patients to their respective wards. In addition, during the discharge process, patients were not subjected to a systematic assessment which was because of not having adequate information in regards to the history of the patient and also letting patients get discharged based on the evaluation of the primary disease only. The study determined that a majority of the physicians mainly focused on the current medical conditions of patients at the expense of their past diagnosis and conditions. This is in a majority of the cases led to constant patient readmissions.
Conclusion
The study attempts to identify the key challenges affecting the effective provision of transitional care to elderly patients. The results indicate that the challenges are interconnected and are mainly as a result of healthcare personnel, caregivers and nurses. This challenges should be effectively addressed through multiple improvement strategies. The study utilized observational data which indicated the unavailability of recent studies and research on transitional care practices therefore negatively affecting the provision of transitional care. It is important to adopt the most appropriate strategies aimed at enhancing the attitude of the key stakeholders involved in transitional care. Again the strategies should improve the knowledge and level of expertise of the different stakeholders involved in the provision of transitional care. The strategies lay a foundation of supporting organizational cultures that are aimed at improving transitional care for elderly patients.
References
Albert, N. M. (2016). A systematic review of transitional-care strategies to reduce rehospitalization in patients with heart failure. Heart & Lung, 45(2), 100-113.
Loeffler, K. (2016). Geriatric intermediate care and transitional care for frailty-related patients: Kerstin Loeffler. The European Journal of Public Health, 26(suppl_1), ckw174-246.
Orvik, A., Nordhus, G., Axelsson, S., & Axelsson, R. (2016). Interorganizational collaboration in transitional care–A Study of a Post-Discharge Programme for Elderly Patients. International journal of integrated care, 16(2).
Vedel, I., & Khanassov, V. (2015). Transitional care for patients with congestive heart failure: a systematic review and meta-analysis. The Annals of Family Medicine, 13(6), 562-571.
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