NURS FPX 6610 Assessment 3 Transitional Care Plan

Transitional Care Plan

Transitional care plays a vital role in safeguarding patient well-being and ensuring quality across different phases of healthcare. It is particularly valuable for individuals with chronic conditions, such as diabetes, who may require continued observation and treatment even after initial recovery. The goal of transitional care is to manage the shift from one care setting to another—like from a hospital to a home environment—without compromising the continuity or effectiveness of the care provided.

This care plan focuses on Mrs. Snyder, a 56-year-old patient admitted to Villa Hospital due to an infected toe resulting from complications associated with diabetes. Given her chronic condition, her treatment requires meticulous coordination, especially during transitions between inpatient care and post-discharge follow-ups. Key considerations in this plan include evaluating necessary treatment elements, identifying communication gaps, and implementing strategies to improve care transitions (Korytkowski et al., 2022).

Key Elements, Patient Needs, and Communication Barriers

To ensure effective transitional care, a range of clinical and logistical components must be integrated into Mrs. Snyder’s care plan. First, her medical records must be thorough and readily accessible. These documents should include her diagnosis, history of diabetes, previous hospitalizations, and coexisting conditions such as hypertension or mental health concerns, which may affect her care outcomes (Chen et al., 2018).

Another critical factor is medication reconciliation. This process verifies that current prescriptions do not conflict with previously administered medications, minimizing the risk of adverse drug interactions (Fernandes et al., 2020). Emergency directives, such as her preferences for future care and cultural values, should also be documented to ensure that her treatment aligns with her expectations and promotes a patient-centered approach (Dowling et al., 2020). Furthermore, access to community support services, including mobility aids, outpatient care, and peer support groups, is essential in aiding her return to daily life (Yue et al., 2019).

Addressing communication barriers is essential to avoid miscommunication, delayed interventions, and potential readmissions. Misunderstandings often stem from incomplete documentation or ineffective use of electronic health record (EHR) systems. For patients like Mrs. Snyder, who may have complex needs, communication must be timely, accurate, and multidisciplinary (Raeisi et al., 2019). Moreover, proper staff training in using digital tools and fostering interprofessional collaboration is key to enhancing care coordination (Tsai et al., 2020).

Strategies for Enhancing Transitional Care

Improving transitional care outcomes requires a systematic and collaborative strategy that integrates hospital care with outpatient or home-based services. Central to this approach is a discharge plan that includes detailed medication lists, dietary instructions, wound care techniques, and follow-up appointments. Ensuring Mrs. Snyder fully understands and adheres to these instructions is crucial to minimizing the risk of infection recurrence or further complications (Glans et al., 2020).

Post-discharge, healthcare providers should maintain communication with Mrs. Snyder through follow-up calls or visits to assess her progress and identify any signs of deterioration. Moreover, empowering her with self-management strategies—such as blood sugar monitoring, proper foot care, and lifestyle adjustments—can greatly improve her long-term outcomes (Spencer & Singh Punia, 2020). These efforts should be supported by digital tools that connect patients to educational materials and provide alerts for medication schedules, appointments, or symptom tracking.

Healthcare professionals involved in her care must coordinate seamlessly across various roles, including nurses, primary care providers, pharmacists, and social workers. This collaborative model not only ensures a unified care plan but also fosters a culture of safety, accountability, and continuous improvement in patient care transitions.

Table 1

Summary of Transitional Care Plan

Conclusion

A well-orchestrated transitional care plan is essential for promoting patient safety and improving health outcomes, especially for individuals with chronic conditions like Mrs. Snyder. By ensuring a patient-centered approach that incorporates accurate documentation, effective communication, and strategic planning, healthcare providers can significantly reduce preventable complications and readmissions. Continuous follow-up and patient empowerment remain the cornerstones of a robust and efficient transitional care model, ultimately enhancing the quality and sustainability of healthcare delivery.

References

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

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

NURS FPX 6610 Assessment 3 Transitional Care Plan

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

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

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 analysis of the content. 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

NURS FPX 6610 Assessment 3 Transitional Care Plan

Yue, P., Wang, Y., Li, J., Zhang, Y., & Zhang, Y. (2019). Effect of community care services on older adults’ health: Evidence from China. BMC Health Services Research, 19(1), 501. https://doi.org/10.1186/s12913-019-4388-2