NURS FPX 6610 Assessment 3 Transitional Care Plan
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Transitional care also impacts the overall quality of patients and their safety. Transitional care may be defined as a chain of care facilities and services that a patient receives under a new phase of treatment. This is more effective, especially in chronic illness where a patient is under regular treatment, and as a remedy to avoid mortality, a transactional care plan can be applied. This assessment is about a woman patient of 56 years named Mrs. Snyder with diabetes who is admitted to Villa Hospital due to the problem of an infected toe. This discussion aims to provide information about the transitional care plan for Mrs. Snyder and foreground some of the communication challenges that can affect the overall transitional plan (Korytkowski et al., 2022).
Key Elements & Information Needed for High-Quality Treatment
The clinical performance ability to deliver high-quality patient care and safety can only be achieved if adequate stipulations are adhered to. The Patient’s diagnosis must be accurate and efficient to avoid issues of “Failure to Diagnose” (Watts et al., 2020). Moreover, the organization must implement a system to help record and archive patients’ history for future use. To solve Mrs. Snyder’s problems, it is essential to diagnose her correctly.
Key Elements
Several crucial factors and data are required from Mrs. Snyder to enhance the quality of the treatment she provides.
Medical Records
One of these entails gathering Mrs. Snyder’s medical records to address her problem immediately. Helping Mrs. Snyder’s medical records allows staff to diagnose other conditions that cause health problems, such as depression, high blood pressure, or heart conditions (FDA 4 R, 2018).
Medication Reconciliation
Healthcare staff must also know Mrs. Snyder’s medication list and other information regarding her physical health. It helps advise whether Mrs. Snyder’s medicine is good for her health and whether she should search for other alternatives. Therefore, the correct documentation of medication reconciliation is needed to help her receive the quality health care she deserves (Fernandes et al., 2020).
Information for Emergency
This care plan necessitates patient-centered care, especially since the staff has to deal with Mrs. Snyder’s religious beliefs, which are critical in her treatment process. It is also crucial for other healthcare sectors to receive advanced directives regarding a patient from primary healthcare providers to understand the status of this patient in the received health sector and what possible errors could arise (Dowling et al., 2020).
Patient Feedback
The other essential factor is the feedback from the patients concerning their behavior and the treatment process from medical personnel. The mental health professional should focus on Mrs. Snyder’s medical needs and want to understand what she will require; thus, the healthcare professionals should always inform the patient of all the relevant information concerning her health needs and treatment process. This will make the patient concentrate her time and energy on health care and neglect those activities that affect her health (Moghaddam A. et al., 2019).
Plan of Care and Education
Another critical issue is that healthcare professionals are experienced in providing patients with the best care and treatment with patient satisfaction. Therefore, the patient’s needs and wants are different; consequently, a transitional care plan is essential. It should be tailored to suit a particular individual or group suffering from a disease or condition. The provision of health services to patients in the community and the rapid sharing of information concerning the patient between the healthcare professionals are other roles and responsibilities, according to Dyer (2021).
Community Health Care Resources
Some community services, such as mobility possibilities, social connectivities, health knowledge, and outpatient care, are needed to prevent hospital readmission and mortality (Yue et al., 2019).
Performance Evaluation of the Perception
All the information required to admit Mrs. Snyder into another healthcare sector is the results of medical tests, records of time in the previous hospital, and lists of prescriptions for the post-discharge period. Furthermore, Mrs. Snyder’s counseling documents, follow-up plans, social assistance, and insurance coverage documents, the current status of Mrs. Snyder’s health status, and the safety enhancement scope via risk assessment and the treatment and drug history are also required (Humphries et al., 2020).
Importance of Key Elements of a Transitional Care Plan
Each of the keys is vital to ensure that the quality of care is improved in transitional care plans. There is a need to gather emergency and advance directive details for patients from past medical and health sectors to plan for every possible problem encountered in treatment and their solutions. It will also be helpful to understand what religion and culture Mrs. Snyder observes to prevent unintentional offense. In their literature review, Blackwood et al. (2019) stated that the advanced directive can assist in ascertaining what is best for the individual’s health in the future. Advance directives will be essential to determine the level at which the patient requires and desires care.
Regarding Mrs. Snyder’s case, the issue will be resolved by supporting community and healthcare resources. She has an infected injury to her toe. Therefore, she should have mobility issues that can be dealt with by providing a room downstairs or an elevator in the organization. She also requires a wheelchair to transport her from one ward to another, and thus, hospitals should be well-equipped with these devices to prevent complications that may result from the patient’s forceful movement. In the journal, Schultz et al. (2021) discussedthea the need for healthcare services and community support to prevent hospital readmission rates. They also mentioned that patients require medical services and facilities after discharge to avoid problems related to severe complications (Schultz et al., 2021). Medication falls under the issue of medication reconciliation because it will assist in identifying the medicines that the patient is allergic to to avert medication errors. Reducing rehospitalization rates should also be avoided. According to the medication, reconciliation will also be necessary because Mrs. Snyder is using insulin. The concerned personnel must ensure that the insulin doses are delivered correctly to avoid dire repercussions. Medical reconciliation as a concept helps eliminate instances of medication errors in healthcare facilities, according to Borulkar et al. (2022). Their journal is concerned with the significance of medication reconciliation in providing care and enhancing safety concerning patient treatment (Borulkar et al., 2022).
Patient comments provide staff with feedback on the status of concern regarding the treatment undergone. Mrs. Snyder developed a toe infection since she had insufficient information on post-discharge procedures, which made her be admitted to reinforce recovery. Henceseekingek the patient’s feedback will help healthcare personnel aavoidnegligence when treating her. Fiorillo et al. (2020) conducted an in-depth analysis of previous research and explained that collecting the patient’s feedback is required to choose treatment. Patients can raise issues they face with the staff, who will give them feedback (Fiorillo et al., 2020).
It was also challenging to determine whether additional education for healthcare professionals and patients could support Mrs. Snyder’s care. During education, the healthcare workers will also learn how they can communicate and work as a team; this is important to consider since it will be used to evaluate the impact on religious and cultural beliefs. It is also essential for Mrs. Snyder to be educated to put the self-management strategies that the nurse mentioned, such as healthy food and daily walks, in place to improve the life that she is living. This implies that every patient has different needs based on the kind of treatment they need, hence the need to plan treatment according to their needs. In their case study, Kaper et al. (2 19) offer a review that shows that training is helpful to healthcare professionals and patients in playing their role in preventing mortalities and improving patient quality (Kaper et al.,2019).
Potential Effects of Incomplete or Inaccurate Information on Care
EHR must be transferred to the other health sector as, ideally, any inconsistency in the information sharing may lead to further delays in treatment and have severe implications for the patient. In addition, if the information is misleading, it can lead to bad outcomes such as incorrect treatment, a rise in the mortality rate, and the rate of patients being readmitted to the hospital. Lack of or partial information can also lead medical errors, whichor patients will not receive if they examine the accurate medication, and the billing staff can remind them to provide the wrong medication, which will affect patients. In the literature review, Zirpe et al. (2020) mention that missing a part of the prescription can lead to medication errors. Unclear or improper information regarding drug-related data causes delays in treatment and death within healthcare facilities (Zirpe, Pollard; Critchley, 2020).
Importance of Effective Communication
The transmittal of information with other healthcare organizations is necessary to acquire the complete patient history. To achieve that, it is essential to maintain effective interaction between the patient and the healthcare staff to increase trust and boost the patient’s commitment to the care plans (Garcia-Jorda et al., 2022). In addition, this connection will help in making decisions for the patient’s welfare. The previous healthcare agency usually provides such information, and it is thus necessary to acquire the proper information to avoid getting false information from the patient. Mrs. Snyder needs collaborative and moral support from her sister as she is under stress and depression because of the exorbitant price of treatment. Communication that is actively practiced decreases the possibility of adverse events and makes demises in the organization as low as possible (Yazdinejad et al., 2020).
Potential Effects of Ineffective Communications
This can have serious adverse effects, such as quick, lousy timing and appropriate intervention delays. In times of crisis, insufficient communication can result in complications, including a patient not getting life-saving treatment once the healthcare team does not have the correct information about the patient. Incorrect communication practices can also result in health disparities that may lead to mortality (Raeisi et al., 2019). Poor communication in the healthcare setting relates to patient care outcomes and quality of care.
Lapses in communication between doctors and patients can also lead to more patient treatment expenses. The information must be transferred suitably to destination HCPs/clients and tested several times, which may lead to duplicative costs. The failure to communicate may also lead to a lack of trust by the patients towards the health professionals and vice versa. It will also mean that the quality of patient care will be reduced due to a lack of satisfaction (Raeisi et al., 2019).
Barriers to the Transfer of Accurate Patient Information
The delivery of an efficient transitional care plan relies on accessing authorized individual information at remote facilities. One fundamental issue that prevents the sharing actual information may be the need for additional appropriate staff. They will state that a nurse or any other employee cannot perform the required duties efficiently during the transition period due to many overloads and obligations. As a result, it could have been negotiated better (Ilardo & Speciale, 2020). Refrain from including results and other diagnostic images or information in medical history is another issue that may require clarification. It is also possible that patients will have to repeat certain tests or undergo other medical procedures because of incomplete medical files – this will cause delays.
Another economic effect of using a repetitive testing strategy may be that insurance may only partially compensate for some costs or even failure to pay for the tests should a different provider not be deemed necessary. The transition healthcare provider may also need more space to cater to the patient’s needs. This is why planning time is required, as well as coordination of information. Hence, one of the most important potential risks that threaten to deteriorate the patient’s health further is the increased demand for the quality and effectiveness of teamwork and communication (Cullati et al., 2019). A lack of knowledge about the usefulness of EHR technology is another factor that could lead to miscommunication. As healthcare professionals fail to receive adequate training on EHRs, information essential to the patient may not be relayed to the destination hospital, leading to potential complications (Tsai et al., 2020).
Strategy to Establish Absolute Understanding of Continued Care
There are different ways to ensure that patients get the adequate care and treatment they deserve. Healthcare professionals need to pass correct information in regards to patients to prevent the occurrence of incidents. Therefore, the strategy to be used is the best practice approach to ensure the information can be planned accurately for transfer to the destination hospitals. In so doing, patients are not financially battered, and reduced mortality rates can also be controlled. The points above are enough to plan for thetransferg of all ofMSnyder’sr’se medical histwas sent ory to the destination hospitals to avoid complications. Furthermore, destination healthcare providers will also receive a medication reconciliation list of Mrs. Snyder, which would prevent them from endangering her with harmful drugs through the wrong administration of medication (Glans et al., 2020).
Another strategy is to hold follow-up interviews with the healthcare providers for them to identify Mrs Snyder’s position in the choice of destination medical center. A joint strategic course is thus needed to prevent possible communication breakdowns and get information on the patient’s concerns immediately. It also means that organizations must pay attention to the discharge instructions for the patient and other prescribers where the patient is being referred to/admitted to, such as which medicines the patient is allergic to and that the patient has to self-manage to lead a healthy life. Healthcare organizations’ strategies will determine whether the transitional care plan is effective (Spencer & Singh Punia, 2020).
Conclusion
The transitional plan is crucial when delivering patients from one medical level to another. This will assist in communicating and transferring every patient’s medical history to other sectors of the healthcare industry to ensure that severe complications and even the loss of lives are prevented. In the case of Mrs. Snyder, this plan will help her to get the best care treatment, and she will learn proper self-management techniques, which will help her live a healthy life and avoid any kind of consequences of diabetes. Strategic planning and post-treatment strategies will also enhance the quality of care offered to patients.
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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), pp. 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
Dyer, E. (2021). It is 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
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 content analysis. 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
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
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