See attachment
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Transitional Care Plan
Learner’s Name
Capella University
NURS-FPX6610: Introduction to Care Coordination
Instructor Name
September 1, 2019
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
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Transitional Care Plan
Transition care plans play an important role in facilitating the effective transition of
patients from one care setting to another. They are critical to the efficient and timely execution of
a broad range of transitional care services, which help promote the utmost safety and quality of
care for patients during transition. This paper will use the simulated case of Mrs. Snyder to focus
on key elements of transitional care, the significance of effective communication in transitional
care, the barriers that inhibit the transfer of information, and strategies to facilitate accurate
patient information transfer. Mrs. Snyder suffers from a terminal illness and has been scheduled
for a transition from a hospital to a hospice facility specializing in end-of-life care.
Key Elements and Information Needed for Ensuring High-Quality Transitional Care
The key elements needed for facilitating qualitative transitional care are as follows:
• Medication reconciliation: It refers to the process of comparing a patient’s prescribed course
of medication against the medication that he/she has been taking until the point of transition
(World Health Care Organization, 2016).
• Communication of patient information to the destination care provider: It is important to
ensure that the destination care provider and the patient are provided with accurate, reliable,
and highly relevant patient information (Li et al., 2014).
• Patient education: Case managers should ensure that patients are duly educated on various
facets of health care such as self-responsibility toward care, better lifestyle choices, and
continuity of care (Naylor et al., 2017). For instance, instructing Mrs. Snyder to opt for
hospice care with continuous chemotherapy accompanied by intravenous steroids and
antiemetics is important to ensure that the transition of care is effective and improves her
outcomes.
Copyright ©2019 Capella University. Copy and distribution of this document are prohibited.
Complete an interactive simulation in which you will make decisions about a patient’s end-of-life care. Then, develop a transitional care plan of 4-5 pages for the patient.
Introduction
Note: Each assessment in this course builds on your work from the preceding assessment; therefore, complete the assessments in the order in which they are presented.
To help reduce care fragmentation, a care coordinator working with patients who suffer from chronic illnesses must share important clinical information with stakeholders so everyone has clear shared expectations about their roles. Equally important, the care coordinator must work with the team to provide updated information to patients and their families and to ensure that effective transitions and referrals take place. This assessment provides an opportunity for you to assume the role of care coordinator and recommend appropriate transitional care for a terminally ill patient.
Relative to other facets of medical care, research directing efforts to improve care coordination has lacked rigor. However, many groundbreaking health care organizations have acknowledged the perils of poorly coordinated care models and applied interventions to improve these models. The objective of care coordination is to secure high-quality recommendations and transitions that aim for superior health care and guarantee that all involved providers, organizations, and patients have the necessary information and resources to make optimal patient care possible.
Note: Complete the assessments in this course in the order in which they are presented.
Preparation
As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.
· What are the likely outcomes of poor care transitions among providers and health care settings?
· Why is effective communication such a vital component of transitional care?
· Where are communication breakdowns likely to occur?
. Why?
. Have you seen or experienced such breakdowns in your own practice setting?
In the previous assessment, you conducted simulated stakeholder interviews and collected information for a plan of care for Mrs. Snyder. Now, seven months later, her condition has deteriorated.
To prepare for this assessment, complete the following simulation:
·
Vila Health: Care Coordination Scenario II
.
In this simulation, you wi
Care Coordination Scenario II
·
Case
·
Interview with Rebecca and Avi Snyder
·
Interview with Rebecca Snyder & Devorah Kaufman
·
Hospice Facility Recommendation
Introduction
One of the most important roles in care coordination is the effective management of patient transition points. Finding the most appropriate facility for a patient—whether a rehabilitation facility, a nursing home, hospice, a home health care situation, or something else—is often a complicated manner. The care coordination team will have to consider the patient’s medical, financial, and social situation. The team will also have to be aware of any relevant regulations, and they need to keep in mind that regulations are subject to change. A facility that seems like an ideal match for a patient may not be feasible for any number of reasons.
In this activity, you will practice making recommendations in the role of a care coordinator who has to find appropriate care for a terminally ill patient. You will see the consequences of less-than-optimal decisions and will have the opportunity to correct these decisions. In the courseroom, you will have the opportunity to apply current regulations to the decisions that need to be made about this particular case.
After completing the activity, you will be prepared to:
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Running head: TRANSITIONAL CARE PLAN 1
Transitional Care Plan
Name
Institution Affiliation
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TRANSITIONAL CARE PLAN 2
Transitional Care Plan
Patient Rebecca Snyder along with relatives and social laborer, was interviewed for the
admitting demographics. Rebecca Snyder is a woman of 56 years of age with a long term obese
Orthodox. Snyder has a past medical history of poorly controlled diabetes, hypertension,
hypercholesterolemia, anxiety, and obesity. She admits to the ED with protests of hyperglycemia
more than 230 for more than ten days, frequent urination, mild abdominal discomfort, malaise,
and dyspnea on exertion. As per the medical records, on date 5th August 2019, the patient was
determined to have Ovarian Cancer, and she was under medication for the condition. Therefore,
the paper aims to explore medical information and outline the nursing care plan for Rebecca
Snyder.
Snyder’s Case on Transitional Care Plan
Healthcare is advancing, and there has been a push to give care in the community rather
than protracted hospitalizations. These advances require a safe, effective, and ideal care plan for
the patient and the family. Naylor et al. (2017) state that transitional care alludes to the
coordination and congruity of medical care while developing a patient starting with one
healthcare setting, then onto the next healthcare setting or the patient’s home. Transitional care
includes the careful coordination and planning of the multidisciplinary group to guarantee a
smooth change for the patient and the family (DelBaccio et al., 2015). Drawing in and teaching
the patient and family concerning the patient’s complex healthcare needs and the requirement for
transitional care require a multidisciplinary team to keep away from disarray and superfluous
readmissions.
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TRANSITIONAL CARE PLAN 3
Key Elements and Informa
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