NURS FPX 6610 Assessment 3 Transitional Care Plan.pdf

Assessment 3: Transitional Care Plan
Student Name
Capella University
NURS-FPX 6610 Introduction to Care Coordination
Prof. Name
June 14, 2024
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Crafting a Seamless Transitional Care Plan
Ensuring patient safety and high-quality care hinges on effective transitional care,
providing advanced facilities and services during patient transitions between treatment
phases. This is particularly critical in managing chronic illnesses, where continuous
monitoring across treatment stages is essential to prevent mortality. This assessment
explores the case of Mrs. Snyder, a 56-year-old diabetic patient admitted to Villa
Hospital for an infected toe. The focus is on developing a transitional care plan for Mrs.
Snyder and identifying communication barriers that may impact the overall plan
(Korytkowski et al., 2022).
Essential Elements and Information for Effective Treatment
Enhancing patient care and safety requires strict adherence to guidelines that ensure
diagnostic accuracy and efficient tracking of medical records. Obtaining Mrs. Snyder’s
medical records is crucial for addressing her health comprehensively. These records aid
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in diagnosing specific health issues and reveal other conditions affecting her overall
health, such as depression, high blood pressure, and heart problems (Chen et al., 2018).
Understanding Mrs. Snyder’s medication list is also critical for ensuring the
appropriateness of her treatment. Medication reconciliation is necessary to assess the
efficacy of her current medication and explore potential alternatives (Fernandes et al.,
2020).
Gathering information about emergency and advance directives is essential for
providing patient-centered care. This helps accommodate religious beliefs and
understand the patient’s treatment history from previous healthcare providers,
minimizing potential conflicts (Dowling et al., 2020).
Patient feedback is a critical component, offering insights into medical personnel
behavior and the treatment process. Addressing patient concerns enhances the
effectiveness of care and reduces the risk of readmissions (Moghaddam et al., 2019).
Developing a Care Plan and Providing Education
Healthcare professionals play a pivotal role in customizing care plans to meet individual
patient needs. This involves providing community-based healthcare services and
facilitating rapid information exchange among healthcare professionals (Dyer, 2021).
Access to community and healthcare resources is vital for preventing adverse
outcomes like hospital readmissions and mortality rates. These resources include
mobility options, social support, health education, and outpatient treatment (Yue et al.,
2019).
A thorough assessment of Mrs. Snyder’s needs requires comprehensive information
such as medical test results, post-discharge prescriptions, time spent in the previous
hospital, counseling documents, follow-up plans, social assistance and insurance
coverage documents, current health condition, safety risk assessments, and detailed
treatment and drug history related to chronic diseases (Humphries et al., 2020).
Importance of Key Elements in a Transitional Care Plan
Each key element in the transitional care plan is crucial for improving patient care.
Advanced directive information aids in preparing for potential issues during treatment,
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while community and healthcare resources directly address patient concerns and needs
(Schultz et al., 2021).
Medication reconciliation ensures accurate and safe administration of medications,
reducing the risk of errors and adverse events (Borulkar et al., 2022). Patient feedback
enhances the understanding of individual patient needs, contributing to more effective
and patient-centered care (Fiorillo et al., 2020).
Healthcare professional training is essential for collaborative and culturally sensitive
care. Education for patients like Mrs. Snyder is crucial for promoting self-management
strategies and adopting a healthier lifestyle (Kaper et al., 2019).
Consequences of Incomplete or Inaccurate Information on Care
Transferring incomplete or inaccurate patient information can lead to treatment delays,
complications, and adverse outcomes. Inaccurate medication information, for example,
may result in errors and increased mortality rates (Zirpe et al., 2020).
Importance of Effective Communication
Effective communication with healthcare agencies is essential for understanding
patients’ detailed medical histories and fostering positive patient-staff interactions. It
plays a crucial role in decision-making for patient well-being (Garcia-Jorda et al., 2022).
Potential Impacts of Ineffective Communication
Ineffective communication can result in delays in timely treatment, health disparities,
increased treatment costs, and reduced patient satisfaction. These factors negatively
impact patient outcomes and the quality of care (Raeisi et al., 2019).
Barriers to Accurate Patient Information Transfer
Barriers include insufficient staff, incomplete medical histories, and a lack of knowledge
about Electronic Health Records (EHR) technology. Overburdened staff may
compromise information accuracy, while incomplete medical records and EHR
knowledge gaps can hinder seamless information transfer (Ilardo & Speciale, 2020; Tsai
et al., 2020).
Strategies for Ensuring Comprehensive Understanding of Continued Care
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Effective planning, accurate information transfer, and follow-up sessions are crucial
strategies to ensure continued care. Collaboration with destination healthcare providers,
complete discharge instructions, and understanding patient perspectives contribute to
successful transitional care plans (Spencer & Singh Punia, 2020).
Conclusion
The transitional care plan is indispensable for transferring patients between healthcare
sectors, preventing complications, and improving overall patient care. Strategic
planning, effective communication, and comprehensive information transfer contribute
to successful transitional care, ensuring the well-being of patients like Mrs. Snyder.
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References
[1] 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.
[2] Borulkar, R., Dhande, P., & Dhande, P. (2022). Medication Reconciliation: A beneficial
tool in patient safety 1 1. Bharati Vidyapeeth Medical Journal (BVMJ), 2(3).
[3] 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).
[4] 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).
[5] 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.
[6] 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.
[7] 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).
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NURS FPX 6610 Assessment 3 Transitional Care Plan.pdf

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