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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.


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


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.


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.


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


Challenge Details


Interview with Rebecca and Avi Snyder

Treatment Recommendation

Case Update

Interview with Rebecca Snyder & Devorah Kaufman

Hospice Recommendation

Hospice Introductions

Hospice Facility Recommendation



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:



Transitional Care Plan


Institution Affiliation

This study source was downloaded by 100000772470296 from on 04-21-2022 14:04:49 GMT -05:00


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’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


This study source was downloaded by 100000772470296 from on 04-21-2022 14:04:49 GMT -05:00


Key Elements and Informa