NURS FPX 6610 Assessment 3 Transitional Care Plan

Name

Capella university

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name

Date

Transitional Care Plan

Ensuring continuity of care during patient transfers is essential to maintaining safety and quality in healthcare. Transitional care is designed to support patients as they move between different levels of care, such as from hospital to home, minimizing the risk of complications and enhancing clinical outcomes. This is particularly crucial for patients managing chronic diseases, like diabetes, who need continuous oversight. This care plan focuses on Mrs. Snyder, a 56-year-old diabetic patient admitted to Villa Hospital for an infected toe. The document explores the core components of her care plan, identifies barriers to effective communication, and outlines actionable strategies to strengthen transitional care (Korytkowski et al., 2022).

Essential Elements of Quality Transitional Care

Quality transitional care requires adherence to several foundational practices. An accurate diagnosis supported by up-to-date medical records is essential to prevent adverse events and tailor treatment appropriately (Watts et al., 2020). For Mrs. Snyder, ensuring the availability of complete health records, conducting medication reconciliation, including patient preferences, and documenting emergency care plans are all vital. Her health history may reveal concurrent issues, such as high blood pressure or emotional distress, which must be considered when crafting her treatment strategy (Chen et al., 2018).

Medication reconciliation is especially important, as it helps prevent harmful interactions and ensures therapeutic alignment (Fernandes et al., 2020). Incorporating advance care planning and acknowledging her cultural beliefs align with patient-centered care principles (Dowling et al., 2020). Access to external resources like social support services, outpatient clinics, and transportation options can further enhance her recovery journey and maintain her quality of life post-discharge (Yue et al., 2019).

Understanding Patient Needs and Communication Obstacles

An effective transitional care plan accounts for individualized needs, such as diagnostic test outcomes, current medication regimens, and previous hospitalization records. Failure to address communication barriers can result in clinical errors, unnecessary readmissions, and increased expenses (Raeisi et al., 2019). These challenges may arise from fragmented documentation, inconsistent team communication, or gaps in electronic health record (EHR) use. Therefore, investing in staff training and optimizing EHR tools is vital for enhancing care coordination (Tsai et al., 2020).

Strengthening Transitional Care with Strategic Approaches

A multidisciplinary approach is key to facilitating a safe transition from hospital to home. Coordinated planning ensures smooth information transfer, particularly discharge summaries and medication lists, which are critical for post-discharge management (Glans et al., 2020). Scheduled follow-up appointments allow healthcare providers to reassess the plan’s effectiveness, identify ongoing issues, and adjust interventions accordingly. Empowering Mrs. Snyder with education on lifestyle changes—such as adopting a diabetic-friendly diet and incorporating physical activity—can significantly improve her long-term health and reduce rehospitalization risks (Spencer & Singh Punia, 2020).

Summary Table: Transitional Care Plan

Heading	Details	References
Key Components	Includes complete medical records, accurate medication reconciliation, emergency care planning, and integration of patient feedback.	Chen et al. (2018); Fernandes et al. (2020); Dowling et al. (2020)
Communication	Effective team communication is necessary to reduce treatment errors, improve satisfaction, and ensure coordinated care.	Garcia-Jorda et al. (2022); Yazdinejad et al. (2020)
Care Challenges	Issues such as incomplete documentation, EHR inefficiencies, and insufficient training impede successful care transitions.	Cullati et al. (2019); Tsai et al. (2020)

Conclusion

In summary, transitional care is pivotal for ensuring that patients like Mrs. Snyder receive comprehensive and continuous treatment throughout their healthcare journey. Addressing communication gaps, promoting interdisciplinary collaboration, and empowering patients through education are key strategies for enhancing care outcomes. By implementing such measures, healthcare organizations can achieve improved clinical effectiveness, patient safety, and satisfaction.

References

Chen, Y., Ding, S., Xu, Z., Zheng, H., & Yang, S. (2018). Blockchain-based medical records secure storage and medical service framework. Journal of Medical Systems, 43(1). https://doi.org/10.1007/s10916-018-1121-4

NURS FPX 6610 Assessment 3 Transitional Care Plan

Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., … & Nendaz, M. R. (2019). When team conflicts threaten the quality of care: A study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43–51. https://doi.org/10.1016/j.mayocpiqo.2018.11.003

Dowling, T., Kennedy, S., & Foran, S. (2020). Implementing advance directives—An international literature review of important considerations for nurses. Journal of Nursing Management, 28(6). https://doi.org/10.1111/jonm.13097

Fernandes, B. D., Almeida, P. H. R. F., Foppa, A. A., Sousa, C. T., Ayres, L. R., & Chemello, C. (2020). Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in Social and Administrative Pharmacy, 16(5), 605–613. https://doi.org/10.1016/j.sapharm.2019.08.001

Garcia-Jorda, D., Fabreau, G. E., Li, Q. K. W., Polachek, A., Milaney, K., McLane, P., & McBrien, K. A. (2022). Being a member of a novel transitional case management team for patients with unstable housing: An ethnographic study. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07590-6

Glans, M., Kragh Ekstam, A., Jakobsson, U., Bondesson, Å., & Midlöv, P. (2020). Risk factors for hospital readmission in older adults within 30 days of discharge – A comparative retrospective study. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-020-01867-3

Korytkowski, M. T., Muniyappa, R., Antinori-Lent, K., Donihi, A. C., Drincic, A. T., … & Umpierrez, G. E. (2022). Management of hyperglycemia in hospitalized adult patients in non-critical care settings: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. https://doi.org/10.1210/clinem/dgac278

Raeisi, A., Rarani, M. A., & Soltani, F. (2019). Challenges of the patient handover process in healthcare services: A systematic review. Journal of Education and Health Promotion, 8(173). https://doi.org/10.4103/jehp.jehp_460_18

NURS FPX 6610 Assessment 3 Transitional Care Plan

Spencer, R. A., & Singh Punia, H. (2020). A scoping review of communication tools applicable to patients and their primary care providers after discharge from the hospital. Patient Education and Counseling. https://doi.org/10.1016/j.pec.2020.12.010

Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of electronic health record implementation and barriers to adoption and use: A scoping review and qualitative analysis of the content. Life, 10(12), 327. https://doi.org/10.3390/life10120327

Watts, G. F., Gidding, S. S., Mata, P., Pang, J., Sullivan, D. R., Yamashita, S., … & Ray, K. K. (2020). Familial hypercholesterolemia: Evolving knowledge for designing adaptive models of care. Nature Reviews Cardiology, 17(6), 360–377. https://doi.org/10.1038/s41569-019-0325-8

Yue, J., Liu, M., Li, J., & Wang, J. (2019). A survey of community health needs and resources for older adults. BMC Health Services Research, 19, 204. https://doi.org/10.1186/s12913-019-4032-7