NURS FPX 6610 Assessment 3 Transitional Care Plan

NURS FPX 6610 Assessment 3 Transitional Care Plan

Name

Capella University

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name

Date

Transitional Care Plan

Patient quality of care and safety are significantly influenced by transitional care. The purpose of transitional care is to provide advanced services when patients transition between different phases of treatment. This is particularly vital for individuals with chronic illnesses, who must be continuously monitored to prevent adverse outcomes, including mortality. A well-structured transitional care plan can address this need. This assessment discusses the case of Mrs. Snyder, a 56-year-old patient with diabetes who was admitted to Villa Hospital due to an infected toe. The focus is on developing a transitional care plan for Mrs. Snyder and addressing potential communication barriers that could affect her overall care (Korytkowski et al., 2022).

Key Elements & Information Needed for High-Quality Treatment

High-quality treatment and safety for patients depend on strict adherence to guidelines that ensure effective diagnosis and care. An accurate diagnosis is crucial to prevent complications (Watts et al., 2020). Maintaining and continuously tracking patient medical records is equally important. For Mrs. Snyder’s care, a precise diagnosis of her condition is vital to understanding her treatment needs. Key elements, such as medical records, medication reconciliation, emergency and advanced directive information, and patient feedback, are essential to improving her quality of care (Fernandes et al., 2020). Each of these elements plays a role in developing a comprehensive care plan tailored to the patient’s needs.

Key Elements

Plan of Care and Education

In addition to clinical data, the education of healthcare professionals and the patient herself is critical. Healthcare providers must be adequately trained to deliver patient-centered care that is both effective and aligned with individual patient needs. For example, professionals must offer community-based healthcare services and collaborate effectively with other providers to ensure seamless transitions (Dyer, 2021). For Mrs. Snyder, having access to community and healthcare resources such as mobility options and outpatient care will help mitigate the risk of hospital readmission due to her chronic condition (Yue et al., 2019).

Insightful Assessment of Patient’s Needs

When transferring Mrs. Snyder to another healthcare facility, it is essential to ensure that all her medical information is communicated clearly. This includes her medical test results, medication lists, discharge prescriptions, and follow-up plans. Comprehensive documentation of her chronic condition history and current treatments must also be shared to prevent treatment delays or errors (Humphries et al., 2020).

Importance of Key Elements in Transitional Care

The key elements of a transitional care plan are essential to improving patient outcomes. For example, advance directives not only prepare healthcare professionals for potential issues but also provide clarity regarding the patient’s preferences for future care. This helps avoid conflicts that could arise due to cultural or religious beliefs (Blackwood et al., 2019). In Mrs. Snyder’s case, access to sufficient community and healthcare resources—such as mobility assistance and social support—can significantly improve her quality of life during recovery from her infected toe (Schultz et al., 2021).

Potential Effects of Incomplete or Inaccurate Information on Care

Failing to transfer complete or accurate information can have devastating effects on patient outcomes. Incomplete data can lead to treatment delays, wrong diagnoses, and increased mortality rates (Zirpe et al., 2020). Inaccurate information, particularly about medications, can result in dangerous drug interactions or errors, exacerbating the patient’s condition. For instance, healthcare staff must know that Mrs. Snyder is on insulin to administer the correct dosage, ensuring her safety (Borulkar et al., 2022).

Effects of Ineffective Communication

Effective communication between healthcare teams is essential to ensuring a seamless care transition. A lack of communication can lead to delays in treatment, increased hospital readmissions, and even death. Mrs. Snyder’s case highlights the need for healthcare staff to engage in clear, continuous communication with previous providers to ensure they fully understand her medical history, treatment plan, and potential concerns (Yazdinejad et al., 2020). Inadequate communication could result in duplicated tests and increased healthcare costs for patients, as well as decreased trust in medical staff (Garcia-Jorda et al., 2022).

Barriers to Accurate Patient Information Transfer

Several barriers can impede the effective transfer of patient information during transitional care. For example, a lack of adequate staffing can cause communication errors or omissions, as overworked healthcare staff may struggle to fulfill their responsibilities (Ilardo & Speciale, 2020). Additionally, incomplete medical histories or insufficient knowledge about Electronic Health Records (EHR) technology can lead to serious miscommunications that adversely affect patient care (Tsai et al., 2020).

Strategies for Ensuring Continued Care

To ensure continuity of care, a comprehensive strategy must be implemented. Healthcare professionals should engage in detailed planning to ensure that all relevant patient information is transferred to the next facility. This includes sharing Mrs. Snyder’s full medical history, medication reconciliation list, and any advanced directives (Glans et al., 2020). Another effective strategy involves follow-up sessions with Mrs. Snyder to ensure that her transition to a new care setting aligns with her needs and preferences (Spencer & Singh Punia, 2020).

Conclusion

A transitional care plan is vital in ensuring that patients receive consistent, high-quality care when moving between healthcare settings. In Mrs. Snyder’s case, the successful implementation of such a plan will provide her with the resources needed to manage her diabetes and recover from her infected toe. By focusing on comprehensive planning, communication, and patient education, healthcare professionals can improve patient outcomes and reduce the likelihood of complications.

References

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

NURS FPX 6610 Assessment 3 Transitional Care Plan

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’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