Client Name
Capella University
NURS-FPX6610: Introduction to Care Coordination
Instructor’s Name
August 2024
Transitional Care Plan
Transitional care is an important aspect of healthcare facilities as it ensures the enhanced care provided to the patients before and after transferring them from one healthcare setting to another (Fakha et al., 2021). These transfers can be within the same hospital from one care unit to another, between different health practitioners, from curative care to hospice. An enhanced and improved plan for transitional care is needed to make sure that adequate health facilities are provided to the patients for better patient outcomes (Earl et al., 2020). This assessment will focus on the transitional care plan for Mrs. Snyder, a 57-year-old woman who was diagnosed with stage 4 ovarian cancer. To manage her deteriorating condition effectively according to her wishes during her transfer from a curative healthcare setting to hospice, a proficient transitional plan was needed to ensure her safety and well-being. The coordination of Mrs. Snyders’s health practitioners and family members can provide significant support in assuring the effectiveness of a transitional plan of care.
Key Plan Elements for High-Quality Transitional Care
The most effective transitional care plan helps to maintain the continuity of the health care provided to the patient during transitions along with ensuring the best quality of care and safety planned and provided to individuals with health issues(Zwart et al., 2021). The safety of patients and health are the most important priority of all healthcare organizations and it is the responsibility of the organization to keep up with the quality until the patient fully recovers or moves to another facility for further treatment. Transitional plans are decided to make transitions carefully, and smoothly, and continue to avoid any kind of disparities (Bajorek & McElroy, 2020). The key elements of a high-quality transition plan are as follows;
Identifying Patient Health Needs
For a smooth and effective transition of a patient from one facility to another it is important to identify the health needs of the patient regarding a particular disease or understand the complete medical history of the patient to provide quality health to the patients and care to the patient during the transition (Nichol et al., 2023). The social and psychological factors of the patient need to be assessed for the helpful transition.
Assessing the Level of Healthcare
After the identification of health needs the assessment of the level of healthcare needed by the patient is also compulsory to make sure that all the health needs of the patient are fulfilled for the successful transition (Hannawa et al., 2021). Careful assessment will lead to beneficial and smooth transition of the patient without causing any health disparities.
Accurate and Transparent Communication
Clear, accurate, and transparent communication is needed between the healthcare professionals, the family members, and the facility where the transition is going to be made (Sheehan et al., 2021). Effective communication is the only factor that can generate accurate transition results without any ambiguity during the transition.
Appropriate Emergency Planning
In case of any emergency, the planning and the required needs should be effective so that the harmful effects of emergencies can be prevented efficiently (Khirekar et al., 2023). Healthcare emergency laws need competent planning and proficient healthcare skills and these need to be included planned and developed in the transition plan for improved outcomes for the patient.
Importance of Key Elements of a Transitional Care Plan
The care plan for transition is of great importance for the effective transition of the patient from one facility of healthcare to another one for better care and treatment of the patients (Park et al., 2024). The key elements of the transition plan ensure that an appropriate and effective transition should be made by keeping in mind the high-quality care and safety of the patients involved in the transition care plan. The importance of key elements of the transition plan of care are given below;
Improved Patient Outcomes
The transition helps in improving patient outcomes by providing high-quality health care to the patients that is effectively and efficiently planned by the coordination of healthcare professionals and family members (Bhati, 2023). Mrs. Snyders’s health is the priority of the transitional care plan and it will ensure her healthy transition.
Reduction in Risk of Clinical Errors
An appropriate and adequate understanding of the health condition of the patient helps in delivering high-quality treatment to the patient (Alemu et al., 2021). In the case of Mrs. Snyder, her healthcare professionals and family members provided sufficient information regarding the healthcare needs of the patient and the protocols need to be administered for the transition.
Decrease in the Rate of Health Disparities
Health disparities will be reduced due to the proper and transparent communication of the healthcare professionals, Mrs. Snyders’s family members, and hospice faculty (Hoagland & Kipping, 2024). Proper communication highlights the important aspects of the needed healthcare thus helping in making sure that the needs of the patient must be fulfilled.
Effective Emergency Response
Mrs. Snyder is incapable of dealing with anxiety and stress hence proper planning of the emergencies during the transition ensures a smooth transition and high-quality care of the patient (Oksholm et al., 2023). Emergencies are always well dealt with when they are planned and processed accurately.
Implications Of Missing Or Inaccurate Information
Missing information regarding a patient’s medical history, societal history or psychological history will harm the patient and the healthcare facility (Butler, 2023). Inaccurate formation can worsen the health condition of the patient and make it impossible to handle for healthcare professionals. The smooth transition of Mrs.Snyder is only because her family and healthcare providers provided complete and accurate information needed for her successful transition from the curative unit to the hospice unit.
Importance of Effective Communications With Health Care And Community Services Agencies
Enhanced communication always has a great and positive impact on generating improved outcomes for the patients and providing a better quality of care to patients (Sharkiya, 2023). Communication that is clear and transparent removes barriers to the effective provision of safety and proficient health care to patients. In the case of Mrs.Snyder, clear communication plays a significant role in ensuring a smooth and coordinated transition from one healthcare setting to another. The importance of effective communication is given below;
High-Quality Care and Safety of Patient
Proficient communication ensures high-quality care of the patient along with enhanced and improved patient safety strategies. It will ensure that the patients will be dealt with and treated according to their health requirements for better patient outcomes.
Supportive and Coordinated Care
One of the major importance of effective and clear communication is that it provides support from the family and the coordinated care of the community agencies, healthcare professionals, and case managers.
Adequate Resource Allocation
Proper adjustment or availability of resources for the transition of patients from one facility to another is of key importance and this can be effectively implemented if the communication channel between the community agencies and healthcare professionals is effective and responsive.
Consequences of Inadequate Communications on Patient Outcomes
Inadequate communication will have dangerous and harmful consequences both for the patient and the healthcare organization as it will lead to health disparities that can not be reversed or handled resulting in a loss of life situation (Sharkiya, 2023). A few consequences are given below;
Risk of Health Disparities
Ineffective communication will lead to high health disparities risking the lives of the patients along with the stress development for the family, community health services, and the healthcare providers which results in a lack of efficiency of the staff members and the transition care plan.
Ineffective Care Coordination
The coordination of care associated with the community agency and the healthcare providers will be disrupted resulting in high health issues and delayed response to the deteriorating patient condition.
Barriers To The Transfer Of Accurate Patient Information
Transparent patient information is of great importance in delivering high-quality health care to patients however inaccurate information can negatively impact the effectiveness of the plan of transitional care and patient safety (Satake & McElroy, 2019). There are many hurdles in the way of transferring accurate information about patients to the community health service agencies involved in the transition of the patient. A few of them are given below;
Lack of knowledge about the use of information technology
Less knowledge regarding information technology and its uses is one of the major barriers to transferring accurate data to other healthcare agencies.
Time Limit
Time limits or inaccurate time of communication can also act as a barrier to transferring accurate information (Methangkool et al., 2019). Most of the time the workload is greater or the transition rate is so high that the staff cannot communicate precisely about the information to the patient.
Language Barrier
People most often couldn’t communicate effectively due to the language barrier. however, some healthcare systems have the facility to translate in the respective language but it still do not create a complete sense of the problem of the communication topic
Ineffectiveness of Patient
The ill condition of the patient creates a barrier in transferring accurate information as the patient is unable to communicate properly about his health condition to the other healthcare professional.
Accuracy And Integrity Of Information Transfer
Accurate information plays an important role for the transition receiving agencies as it lets them understand the need for healthcare required by the patient along with any other social healthcare needs. This information needs to be secure and confidential so that only people with authorization and authentication can access this information.
Strategy For Ensuring That The Destination Care Provider Has An Accurate Understanding Of Continued Care
To make sure that the care agencies at the destination have accurate information regarding the patient proper documentation of the information should be done and provided to the destination care providers (Bradley et al., 2022). Proper monitoring and follow-up of the information is necessary to ensure that the information reached at the destination is valid and accurate. An effective list of the medication needed by the patient under different situations should be documented and communicated to the healthcare providers at the destination.
The collaboration of family, case managers, and interdisciplinary teams in delivering accurate information to the destination is of significant importance as they can effectively communicate with the destination care providers for better patient outcomes. Electronic health records must be updated and accurate consisting of the complete medical, social, economic, and psychological history of the patient (Wang et al., 2023). The call and meeting for the confirmation of the mail must be scheduled and conducted with accurate measures.
NURS FPX 6610 Assessment 3 Conclusion
The importance of a transitional care plan in transferring a patient from one healthcare to another health care facility is undeniable as it makes sure that the patient reaches their destination safely and smoothly (Fakha et al., 2021). Identifying the requirements of the patient to be transferred, documenting the healthcare needs of the patient and the successful implementation of the transitional care plan are the major components of the transition. Effective communication and popular support and coordination from the family members and healthcare professionals make this transition more successful and accurate (Sheehan et al., 2021). However, sometimes inaccurate information leads to health disparities, and some barriers to transferring accurate information at the destination result in harmful impacts on the patients and the healthcare facilities.
NURS FPX 6610 Assessment 3 References
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