NURS FPX 6610 Assessment 3 Transitional Care Plan

Assessment 3 Transitional Care Plan

Student Name

Capella University

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name

Date

Transitional Care Plan

Patient quality of care and safety also depends upon transitional care. The purpose of transitional care is to provide advanced facilities and services when patients are transferred from one treatment phase to another. Especially in chronic illness, patients must be monitored continuously in every phase of treatment to avoid mortality, which a transactional care plan can do. This assessment discusses the case of Mrs. Snyder 56-year-old patient who has diabetes and comes up in Villa Hospital with the issue of an infected toe. This assessment is designed to discuss the transitional care plan for Mrs. Snyder and what communication berries can affect the overall transitional plan (Korytkowski et al., 2022). 

Key Elements & Information Needed for High-Quality Treatment 

Patient quality of care and safety can be improved only when strict guidelines are in place to assure effectiveness. The Patient’s diagnosis must be made with precision and effectiveness to avoid complications (Watts et al., 2020). Additionally, it is also important that the organization track patient medical records continuously and store them for future needs. In order to understand Mrs. Snyder’s issues, it is important to diagnose her properly. 

Key Elements 

Various key elements and information is needed from Mrs. Snyder to improve her quality of treatment. 

Medical Records 

One of them is to collect the medical records of Mrs. Snyder, with which her problem can be addressed easily. With the help of Mrs. Snyder’s medical records, staff can diagnose other health problems affecting patient health, like depression, high BP, and heart issues (Chen et al., 2018).

Medication Reconciliation

In addition to medical records, healthcare staff also needs to know about the medicine list that Mrs. Snyder is taking. The medicine list ensures whether Mrs. Snyder’s medicine benefits her health or if she needs other substitutes. So proper medication reconciliation is necessary to improve Mrs. Snyder’s quality of treatment (Fernandes et al., 2020).   

Emergency and Advance Directive Information

A transactional care plan demands patient-centered care as staff must focus on Mrs. Snyder’s religious mindset, which will help her in various treatment steps. It is also important for healthcare sectors to get advance directive information about the patient from primary healthcare providers to learn about the treatment the patient is getting in the previous health sector to avoid serious issues (Dowling et al., 2020). 

Patient Feedback 

Along with this, another key element includes patient feedback regarding medical personnel behavior and treatment process. This will help to know about Mrs. Snyder’s medical needs and wants, so healthcare professionals must provide Mrs. Snyder with all the important information regarding her condition and treatment process. This will encourage the patient to focus on her health care and avoid activities affecting her health (Moghaddam.A.et al., 2019). 

Plan of Care and Education 

Another key element is that healthcare professionals are also well-trained to provide the best care treatment to the patients with satisfied patient satisfaction. Every patient have different needs and wants, so it is important to develop a transitional care plan according to patient requirement and conditions. Healthcare professionals are responsible for providing patients with various community-based healthcare services and sharing information rapidly with other healthcare professionals (Dyer, 2021).

Community and Health Care Resources

Avoiding negative medical outcomes like hospital readmissions and mortality rates requires sufficient community services like mobility options, social support, health education, and outpatient treatment (Yue et al., 2019).

Insightful Assessment of the Patient’s Needs

Information needed to transfer Mrs. Snyder to another healthcare sector is medical test results, a list of Mrs. Snyder’s post-discharge prescriptions, and time spent in the previous hospital. Additionally, Mrs. Snyder’s counseling documents, follow-up plans, social assistance and insurance coverage documents, Mrs. Snyder’s current health condition, enhanced safety risk assessments, and thorough treatment and drug history associated with chronic diseases are also required (Humphries et al., 2020). 

Importance of Key Elements of a Transitional Care Plan

Every key element is essential in transitional care plans with which patient quality of care can be improved. It is important to collect patient emergency and advance directive information from previous healthcare sectors so that healthcare professionals prepare for every issue that can come up in the treatment and how to resolve them. It will also help to know about Mrs. Snyder’s religious and cultural beliefs to avoid conflicts. In their literature review, Blackwood et al. (2019) suggested that advance directive helps make future health decisions. Advanced care planning will help to assess patients’ needs and wants.  In the case of Mrs. Snyder, community and healthcare resources will help to resolve her concerns. She is suffering from an infected toe, so she should have walking problems that can be resolved if she gets room on the ground floor or if the organization has elevator facilities. She also needs a wheelchair to move from one ward to another, so hospitals must ensure they have sufficient facilities to avoid serious complications. In the journal, Schultz et al. (2021) provide the importance of healthcare services and community support to prevent hospital readmission rates. Moreover, they also said that patients need medical services and facilities after discharge to avoid serious issues (Schultz et al., 2021).  

NURS FPX 6610 Assessment 3 Transitional Care Plan

Along with this, medication reconciliation plays an important role as it will help access the medicine the patient is allergic to so that medication errors will be avoided. Along with this, patient readmission rates should also be avoided. Medication reconciliation will also address that Mrs. Snyder is on insulin, so healthcare staff must provide her with accurate insulin doses to prevent dangerous consequences. Borulkar et al. (2022), in their journal, give a viewpoint that medical reconciliation can help to avoid medication errors in healthcare organizations. Their journal focuses on the importance of medication reconciliation towards patient care treatment and safety (Borulkar et al., 2022).  With patient feedback, staff can assess patient concerns towards treatment. Mrs. Snyder suffered from a serious toe infection due to less awareness about post-discharge guidelines, which led her to readmit to the hospital. So healthcare staff requires patient feedback to avoid this type of negligence while treating her. Fiorillo et al. (2020) provide a literature review and describe that patient feedback is necessary to make a treatment decision. Staff will learn about patient concerns through feedback (Fiorillo et al., 2020).

NURS FPX 6610 Assessment 3 Transitional Care Plan

Additionally, healthcare professionals and patients’ advanced training could help to improve Mrs. Snyder’s quality of care. With training, healthcare professionals learn about effective collaboration and communication, which will help to assess patients’ religious and cultural beliefs. Additionally, educating Mrs. Snyder is significant so that she can adopt self-management tactics (eating healthy food and going for walks daily) to improve her well-being and lifestyle. Every patient has different requirements and treatments, so it is important to develop a care plan according to patient requirements. In their case study, Kaper et al. (2019) provide a review that training is necessary for healthcare professionals and patients to avoid mortality rates and improve patient quality of care (Kaper et al., 2019).

Potential Effects of Incomplete or Inaccurate Information on Care

Transferring complete information about patients from one healthcare sector to another is important, as incomplete information can cause delays in treatment and serious complications. Along with incomplete information, if the information is inaccurate, it can cause serious consequences like wrong treatment, increased mortality, and readmission rates. Incomplete information can also cause medication errors. Staff will not get an accurate medication list of patients, and they can give the wrong medicine, which can have an adverse effect on patients. In their literature review, Zirpe et al. (2020) provide a review that an incomplete prescription list can also cause medication errors. Incomplete drug information delays treatment and increases mortality rates within healthcare organizations (Zirpe et al., 2020).  

Importance of Effective Communication

Effective communication with other healthcare agencies is necessary to know about patients’ medical history in detail. Effective interaction is essential in developing a positive interaction between the patient and the healthcare staff, which raises the patient’s level of trust and encourages commitment to care plans (Garcia-Jorda et al., 2022). Along with this, effective communication will help make decisions for patient well-being. To know about patients’ recent conditions, healthcare staff must communicate with previous healthcare agencies to avoid collecting information inaccurately. Mrs. Snyder is suffering from stress and depression due to the high cost of treatment, so she needs effective collaboration and moral support to get rid of depression and anxiety. Effective communication reduces the chances of adverse events and mortality rates within the organization (Yazdinejad et al., 2020). 

Potential Effects of Ineffective Communications

Ineffective communication can cause serious consequences like quick, timely, and appropriate treatment delays. In case of any emergency, lack of ineffective communication can cause serious issues like patients will not get immediate treatment as healthcare staff did not have accurate information about patients. Ineffective communication can also lead to serious health disparities, which can cause death (Raeisi et al., 2019). Ineffective communication can negatively affect patient treatment outcomes and quality of care.  Due to ineffective communication, patient cost of treatment can also be increased because of an absence of communication. As information is not provided appropriately to destination healthcare providers, patients get repeated tests, which can cause unnecessary expenses. Ineffective communication can also cause a lack of trust and patient satisfaction toward healthcare professionals. Due to a lack of satisfaction, patient care quality will also be affected (Raeisi et al., 2019). 

Barriers to the Transfer of Accurate Patient Information

An effective transitional care plan depends on transferring proper information to destination hospitals. The lack of sufficient staff may be one of the actual obstacles to sharing accurate information. During the transitioning period, a nurse or any other staff member will be unable to perform their jobs effectively due to excessive burdens and responsibilities. Therefore, it could miscommunicate information (Ilardo & Speciale, 2020).  Uncompleted medical histories are another barrier, such as missing test results and other diagnosis documents, which may cause miscommunication. Due to incomplete medical records, time will be wasted if testing and other medical procedures must be redone.

NURS FPX 6610 Assessment 3 Transitional Care Plan

Due to the possibility that insurance may not always pay for repeated testing, it may also place an economic burden on the patient and their family. Sometimes, the transitional healthcare provider may need more room to accommodate patients’ needs. Planning and information sharing are essential as a result. Therefore, one of the main potential obstacles that can result in the patient’s health state getting worse is a lack of effective teamwork and clear communication (Cullati et al., 2019). Lack of knowledge about Electronic Health Records (EHR) technology is another potential barrier that can cause miscommunication. Due to this, accurate patient information will not be transferred to the destination hospital because of a lack of training in healthcare professionals regarding EHR technology, which can cause serious issues (Tsai et al., 2020). 

Strategy to Establish Absolute Understanding of Continued Care

Various strategies can help to provide patients with effective care treatment. Healthcare professionals must get proper and correct information about patients to avoid issues. So best practice strategy is to develop appropriate planning so that accurate information will be transferred to the destination hospitals. By doing so, patients do not have to face financial burdens, and the mortality rates can also be avoided. By proper planning, Mrs. Snyder’s full medical history will be transferred to the destination hospitals to prevent serious complications. Along with this, destination healthcare providers will also get a medication reconciliation list of Mrs. Snyder which will avoid adverse events due to the wrong medication (Glans et al., 2020).  Another strategy is to conduct follow-up sessions with which healthcare providers will understand Mrs. Snyder’s perspective regarding the destination medical center. It is important to develop a collaborative strategic approach to avoid communication gaps and get to know about patients’ concerns easily. Along with this, organizations must focus on providing complete discharge instructions to the patient and other destination healthcare providers, like which medicine Mrs. Snyder is allergic to, and she has to adopt a self-management plan of care to live a healthy lifestyle. The transitional care plan will be successful if healthcare organizations focus on these strategies (Spencer & Singh Punia, 2020). 

Conclusion

The transitional care plan is important when transferring patients from one healthcare sector to another. It will help to transfer the complete patient medical history to other healthcare sectors so that serious complications and mortality rates can be avoided. In the case of Mrs. Snyder, this plan will help her to get the best care treatment and learn about self-management techniques to live a healthy lifestyle and get rid of diabetes-related serious consequences. Along with this, proper planning and follow-up strategies will also help to improve the quality of care treatment for patients. 
References
Moghaddam, M. A.A., Zarei, E., Bagherzadeh, R., Dargahi, H., & Farrokhi, P. (2019). Evaluation of service quality from patients’ viewpoint. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-3998-0 Blackwood, D. H., Walker, D., Mythen, M. G., Taylor, R. M., & Vindrola-Padros, C. (2019). Barriers to advance care planning with patients as perceived by nurses and other healthcare professionals: A systematic review. Journal of Clinical Nursing, 28(23-24), 4276–4297. https://doi.org/10.1111/jocn.15049 Borulkar, R., Dhande, P., & Dhande, P. (2022). Medication Reconciliation: A beneficial tool in patient safety 1 1. Bharati Vidyapeeth Medical Journal (BVMJ), 2(3). https://bvmj.in/journal/borulkar_2022.pdf 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 Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Junod Perron, N., Bajwa, N. M., Viet Vu, N., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & 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 
NURS FPX 6610 Assessment 3 Transitional Care Plan
Dyer, E. (2021). It’s about people: Caring agents and satisfied patients are key to a successful healthcare call center culture. Management in Healthcare, 6(2), 134–141. https://www.ingentaconnect.com/content/hsp/mih/2021/00000006/00000002/art00004 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 Fiorillo, A., Barlati, S., Bellomo, A., Corrivetti, G., Nicolò, G., Sampogna, G., Stanga, V., Veltro, F., Maina, G., & Vita, A. (2020). The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review. Annals of General Psychiatry, 19(1). https://doi.org/10.1186/s12991-020-00293-4 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 Humphries, C., Jaganathan, S., Panniyammakal, J., Singh, S., Dorairaj, P., Price, M., Gill, P., Greenfield, S., Lilford, R., & Manaseki-Holland, S. (2020). Investigating discharge communication for chronic disease patients in three hospitals in India. Plos One, 15(4), 0230438. https://doi.org/10.1371/journal.pone.0230438 Ilardo, M. L., & Speciale, A. (2020). The community pharmacist: Perceived barriers and patient-centered care communication. International Journal of Environmental Research and Public Health, 17(2). https://doi.org/10.3390/ijerph17020536
NURS FPX 6610 Assessment 3 Transitional Care Plan
Kaper, M. S., Winter, A. F. de, Bevilacqua, R., Giammarchi, C., McCusker, A., Sixsmith, J., Koot, J. A. R., & Reijneveld, S. A. (2019). Positive Outcomes of a Comprehensive Health Literacy Communication training for health professionals in three European countries: A multi-center pre-post intervention study. International Journal of Environmental Research and Public Health, 16(20), 3923. https://doi.org/10.3390/ijerph16203923 Korytkowski, M. T., Muniyappa, R., Antinori-Lent, K., Donihi, A. C., Drincic, A. T., Hirsch, I. B., Luger, A., McDonnell, M. E., Murad, M. H., Nielsen, C., Pegg, C., Rushakoff, R. J., Santesso, N., & 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 Schultz, B. E., Corbett, C. F., Hughes, R. G., & Bell, N. (2021). Scoping review: Social support impacts hospital readmission rates. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16143 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., Raal, F. J., Santos, R. D., & 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
NURS FPX 6610 Assessment 3 Transitional Care Plan
Yazdinejad, A., Srivastava, G., Parizi, R. M., Dehghantanha, A., Choo, K.-K. . R., & Aledhari, M. (2020). Decentralized authentication of distributed patients in hospital networks using blockchain. IEEE Journal of Biomedical and Health Informatics, 24(8), 2146–2156. https://doi.org/10.1109/JBHI.2020.2969648 Yue, D., Pourat, N., Chen, X., Lu, C., Zhou, W., Daniel, M., Hoang, H., Sripipatana, A., & Ponce, N. A. (2019). Enabling services to improve access to care, preventive services, and satisfaction among health center patients. Health Affairs, 38(9), 1468–1474. https://doi.org/10.1377/hlthaff.2018.05228 Zirpe, K., Seta, B., Gholap, S., Aurangabadi, K., Gurav, S. K., Deshmukh, A. M., Wankhede, P., Suryawanshi, P., Vasanth, S., Kurian, M., Philip, E., Jagtap, N., & Pandit, E. (2020). Incidence of medication error in critical care unit of a tertiary care hospital: Where do we stand? Indian Journal of Critical Care Medicine, 24(9), 799–803. https://doi.org/10.5005/jp-journals-10071-23556

ADDITIONAL INSTRUCTIONS FOR THE CLASS – NURS FPX 6610 Assessment 3 Transitional Care Plan

Who we are

We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.

Do you handle any type of coursework?

Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.

Is it hard to Place an Order?

  • 1. Click on “Order Now” on the main Menu and a new page will appear with an order form to be filled.
  • 2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
  • 3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
  • 4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
  • 5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.

SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS – NURS FPX 6610 Assessment 3 Transitional Care Plan

We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
  • Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.
  • Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week. NURS FPX 6610 Assessment 3 Transitional Care Plan
  • APA Format and Writing Quality
Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.
  • Use of Direct Quotes
I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.
  • LopesWrite Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score. NURS FPX 6610 Assessment 3 Transitional Care Plan
  • Late Policy
The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
  • Communication
Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. NURS FPX 6610 Assessment 3 Transitional Care Plan

    SCORE A+ WITH HELP FROM OUR PROFESSIONAL WRITERS

    We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. Looking for a Similar Assignment? Order a custom-written, plagiarism-free paper