Transition Care

The elderly are living longer with multiple complex and chronic illnesses. Hospitalization can occur for management of these conditions. After a short hospital stay, many are discharged to lower acuity settings such as home, nursing home, or rehabilitation centers. Unfortunately, many patients are re-admitted back to the hospital due to challenges in transitioning between care settings.

The purpose of this assignment is to:

· Understand the transitional care process

· Identify common challenges and barriers

· Explore strategies for improving care transitions

· Reflect on your role as a BSN-prepared nurse in supporting safe and effective transitions

Project Overview

For this project, you will watch the Robert J Woods Foundation videos, take the associated 15-point quiz, interview a healthcare professional experienced in transitional care, and write a 50-point paper focused on the transitional care process.

You DO NOT have a patient for this assignment.

Project Instructions

Prepare

1. Read assigned textbook chapters in Module 3.

2. Explore credible websites & journal articles.

3. Watch all Care About Your Care (CAYC) videos. Take notes on:

· Strategies used

· Organizations involved

· Locations

· Outcomes (especially reduction in readmission strategies)

4. Create interview questions focused on challenges and barriers in care transitions.

5. Interview a healthcare professional experienced in transitional care (e.g., RN discharge planner, social worker, NP, PA).

6. Identify and reflect on the role of the BSN nurse in supporting care transitions. Consider the leadership role, such as:

· Communicating with patients, families, and discharge facilities

· Teaching self-care starting at admission

Complete the CAYC Quiz (15 points)

1. Take the quiz on D2L after watching all the CAYC videos.

2. Use your notes to answer questions about organizations, strategies, and outcomes.

Write the Essay (50 points)

1. Length: 950–1000 words (body only). Points may be deducted if outside this range. (1 point)

2. Structure

a. Title page (not included in word count)

b. Body: Use Level 1 APA headings (Centered and bold) for each section: (10 points for each section)

i. Introduction (2 points)

Identifies the main purpose and main points

ii. Transitional Care Overview (10 points)

Define transitional care, describe the issue, and explain its impact on older adults.

iii. Strategies (10 points)

Discuss at least 2 organizations and strategies for improving outcomes and reducing readmissions from the CAYC videos.

iv. Interview Summary (10 points)

Use initials only to introduce the person and summarize the questions asked and responses received.

Describe the professional’s role, setting, and insights on challenges and facilitators in care transitions.

v. BSN Role (10 points)

Reflect on how BSN nurses contribute to transitional care, including patient education and communication.

vi. Conclusion (2 points)

Summarize the key points and connect back to your introduction

c. References (not included in word count): within the last 10 years (2 points)

NURS 420-TC Project-SU2022©NS

Edited 9.2025 & 8.2026 JPederson

2 | P a g e