System of Transition of Care

Udod, S. A., & Lobchuk, M. (2017). The Role of Nurse Leaders in Advancing Carer Communication Needs across Transitions of Care: A Call to Action. Nursing Leadership, 30(1).

According to this article, transition care involves a wide array of services that are time-limited planned to make sure that there is health stability; there is the prevention of avoidable poor results among in danger populations as well as the encouragement of secure and well-timed relocation of patients from one stage of care to the other. In the hospital settings, the transition begins when a skilled nurse establishes that the individual is steady enough to leave for their home or have a short period therapy plan in a skilled nurture facility. Similarly, it can start in the office of the doctor discovers a troublesome symptom. I am going to focus on transiting the aged patients in the hospital setting to family-centered care. This is an opportunity of focusing on the person and family-centered care. The transition means more than the physical changes of the settings, but they also entail new tasks, interaction as well as other transformations.

Transitions are the susceptible switch over points that normally contribute to unnecessarily elevated rates of health services use as well as healthcare expenditure and also the exposure recurrently ill people to quality and safety lapses. It is during the transition period that errors usually happen. This error includes medication information that a patient may have been given while in the hospital might be inaccurately communicated to the area where the patient is discharged. Also, the transition can lead to unpleasant clinical events to the patients who lead to severe unmet requirements as well as the patient’s poor satisfaction with care.

Rennke & Ranji (2015) believes that one of the most significant issues that are facing the industry of healthcare is the number of aging patients who are suffering from chronic ailments. Transit’s care hallmark focuses on highly susceptible, persistently ill patients all through the critical transition in health and healthcare as well as the emphasis of giving patients proper education to avoid re-hospitalization. Almost 20% of patients are readmitted for treatment within 30 days of release from hospitalization, showing that there are discrepancies in the healthcare industry. In responding to the growing numbers and inconsistencies within the healthcare industry, there is a need for addressing and mitigating the various problems being witnessed.

For instance, the reduction of acute hospital care for patients with conditions that are long term is one of the issues that have become very significant health policy, as the government is aiming at containing the escalating costs of healthcare costs. It is, therefore, crucial to avoid acute episodes in elderly patients, which are a goal itself to be met. This can only be met by providing better acute care.

The acute care setting inclusion in the management of chronic illnesses is very important. This is for the reason that even when ideally managed, patients with chronic illness are admitted to the hospitals frequently. It has been observed that one of the most effective ways of managing chronic diseases, especially when it comes to the age group, is putting the patients in the ambulatory setting. In the chronic care model, for instance, it insists that the ambulatory settings support the development of informed, activated patients as well as healthcare teams that are well prepared to improve the outcomes of the patient. Hospitals remain responsible for specific interventions, and there is a need for nurses coming up with strategies of engaging and assisting patients as they move between multiple care settings.

During the transition care of the elderly patients from the hospital into the family, there are various stakeholders involved that is very important is supporting this process. According to this article, this kind of transition identifies and deals with family needs and references, integrating family caregivers as associates in the care. One of the biggest stakeholders is the nurse. In the healthcare environment today, the transition is ever-present. It is opposed to being seen as a high-risk endeavor where nursing is capable of playing a very critical responsibility in aiding care. Nurses from corner to corner of all levels of care are idyllically positioned to lead through innovations as well as execution of a patient-centered process, which ensures that there is a very effective transition in care, thus bringing a positive impact in health outcomes (Manias et al., 2019). As a nurse leader, I would encourage excellent communication between the family and the nurses to ensure that the patients and the family members are given proper education regarding the dos and the don’ts.

The other very critical stakeholder is the family members. The broad term of family caregiver refers to any individual who is significantly related to the patient providing a broad range of assistance for the older adult with chronic conditions as the healthcare needs of the older patient become complex. They normally face the challenge of managing medications across transition care. This is where the family comes in as they play a major role in the lives of the patients.

The families are vigorously engaged with older patients in the process of ensuring that older patients manage their medication well across the transition of care. This is important as the family helps in giving and receiving information, making critical decisions, managing medication complexity as well as managing medication complexity. They, therefore, play a critical role in ensuring the safe management of medication. The improvement that should be made is regarding communication concerning prescription plans of care across the transition, which tends to be disorganized and jumbled.

Another adjustment is concerning collective decision making between the families and the health experts. The patients are also a very important stakeholder during the transition care. This is because this method is aware of the capability of older people who have cognitive impairments that are mild to moderate, giving them an opportunity of expressing their desires about their daily activities and participating in numerous decisions.

Batcheller et al. (2017) believe that it is the aim of every nurse leader that, at the end of the day, the lives of the patients they serve are improved. This can only be achieved through the quality of care that is provided to the patients as well as the satisfaction of the patients, which are the foundation of every institution. The quadruple aim is one of the most important models that I can use as a nurse leader to improve patient care as well as quality outcomes. This focuses on the experience of the patients, the reduction of the total cost of care, population health, and the focus aspect is the improvement of the well-being of the workforce.

Leaders, as well as providers of healthcare, should add the fourth dimension in developing the work-life of the people they are working with to “ensure better care, better health and lower costs of healthcare” (Batcheller et al., 2017). In achieving the forth aim, as a nurse leader, there are various strategies that I would implement to boost the satisfaction of my team. One of the important ways is through the implementation of team documentation.

Team documentation is one of the ways that has been singled out as having greater satisfaction of the staff, better revenues, as well as having the capacity of handling large panel of patients and be able to leave early for their homes. Secondly, I would expand roles, thus letting nurses and medical assistants assuming responsibilities for preventive care as well as chronic care health education under the physician standing orders. Lastly, I would try everything to ensure that I avoid shifting burnout of my support team by making sure that any staffs who take new responsibility are trained well and well understands that they are contributing to the health of their patients which means that there is no redundant work that is reengineered out of practice.

System thinking is a mindset that helps me review systems as well as their subcomponents as intimately interrelated and connected (Carey et al., 2015). According to IOM reports, the common medical mistakes are a consequence of flawed systems and procedures but not individual processes. It is, therefore, important that we adopt various processes that identify inefficiencies, unproductive care, as well as avoidable mistakes. One of the important strategies that I would use is quality improvement by observing the structure, processes, and outcomes. The structure will focus on the accessibility, the availability as well as the quality o resources.

The process measures, on the other hand, will look at the healthcare services delivery by my team. The outcome measures will, on the other hand, look at the final results of healthcare. This can be influenced by factors such as the environment as well as behaviors. This will, therefore, look at how the patients are satisfied, what are the mortality rates as well as the improvement of health status. This will be made possible by the implementation of the sigma model, which helps in improving, designing as well as monitoring processes aimed at ensuring that there is no wastage and helping in satisfaction maximization and financial stability.

References

Batcheller, J., Zimmermann, D., Pappas, S., & Adams, J. M. (2017). Nursing's leadership role in addressing the quadruple aim. Nurse Leader, 15(3), 203-206.

Carey, G., Malbon, E., Carey, N., Joyce, A., Crammond, B., & Carey, A. (2015). Systems science and systems thinking for public health: a systematic review of the field. BMJ open, 5(12), e009002.

Manias, E., Bucknall, T., Hughes, C., Jorm, C., & Woodward-Kron, R. (2019). Family involvement in managing medications of older patients across transitions of care: a systematic review. BMC geriatrics, 19(1), 95.

Rennke, S., & Ranji, S. R. (2015). Transitional care strategies from hospital to home: a review for the neurohospitalist. The Neurohospitalist, 5(1), 35-42.

Udod, S. A., & Lobchuk, M. (2017). The Role of Nurse Leaders in Advancing Carer Communication Needs across Transitions of Care: A Call to Action. Nursing Leadership, 30(1).