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Assessment 3: Transitional Care Plan

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Student Name

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Capella University

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NURS-FPX 6610 Introduction to Care Coordination
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Prof. Name

FEB 25, 2024

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Creating a Care Plan for Transitional Care

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Ensuring patient safety and quality care relies heavily on transitional care, which aims to
provide advanced facilities and services when transferring patients between treatment
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phases. Particularly crucial in chronic illnesses, continuous monitoring across treatment
phases is essential to prevent mortality. This assessment delves into the case of Mrs.
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Snyder, a 56-year-old patient with diabetes admitted to Villa Hospital for an infected toe.
The focus is on crafting a transitional care plan for Mrs. Snyder and identifying
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communication obstacles that may affect the overall transitional plan (Korytkowski et al.,
2022).
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Essential Components & Necessary Information for Effective Treatment

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Improvements in patient care and safety depend on strict adherence to guidelines

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ensuring precision in diagnosis and effective tracking of patient medical records.

Obtaining Mrs. Snyder’s medical records is crucial for addressing her health issues
comprehensively. These records not only assist in diagnosing specific health problems
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but also reveal other issues affecting overall health, such as depression, high blood
pressure, and heart conditions (Chen et al., 2018).
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In addition to medical records, understanding Mrs. Snyder’s medication list is vital for
ensuring the appropriateness of her treatment. Medication reconciliation is necessary to
determine the efficacy of her current medication and explore potential substitutes
(Fernandes et al., 2020).

Obtaining information about emergency and advance directives is essential for

providing patient-centered care. It helps in accommodating religious beliefs and
understanding the patient’s treatment history from previous healthcare providers,
minimizing potential conflicts (Dowling et al., 2020).

Patient feedback serves as a crucial element, offering insights into medical personnel
behavior and the treatment process. Addressing patient concerns enhances the

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effectiveness of care and minimizes the risk of readmissions (Moghaddam et al., 2019).

Care Plan Development and Education

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Healthcare professionals play a pivotal role in tailoring care plans to meet individual
patient requirements. This involves providing community-based healthcare services and

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facilitating rapid information exchange among healthcare professionals (Dyer, 2021).

Access to community and healthcare resources is vital for preventing adverse outcomes
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like hospital readmissions and mortality rates. These resources include mobility options,
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social support, health education, and outpatient treatment (Yue et al., 2019).

An insightful assessment of Mrs. Snyder’s needs requires comprehensive information

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such as medical test results, post-discharge prescriptions, time spent in the previous
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hospital, counseling documents, follow-up plans, social assistance and insurance

coverage documents, current health condition, safety risk assessments, and detailed
treatment and drug history related to chronic diseases (Humphries et al., 2020).
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Significance of Key Elements in a Transitional Care Plan

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Each key element in the transitional care plan is integral to improving patient care.
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Advance directive information aids in preparing for potential issues during treatment,
while community and healthcare resources directly address patient concerns and needs
(Schultz et al., 2021).
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Medication reconciliation ensures accurate and safe administration of medications,

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reducing the risk of errors and adverse events (Borulkar et al., 2022). Patient feedback
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enhances the understanding of individual patient needs, contributing to more effective
and patient-centered care (Fiorillo et al., 2020).

Healthcare professional training is essential for collaborative and culturally sensitive

care. Education for patients like Mrs. Snyder is crucial for promoting self-management
strategies and adopting a healthier lifestyle (Kaper et al., 2019).

Potential Consequences of Incomplete or Inaccurate Information on Care

Transferring incomplete or inaccurate patient information can lead to treatment delays,

complications, and adverse outcomes. Inaccurate medication information, for instance,
may result in errors and increased mortality rates (Zirpe et al., 2020).

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The Importance of Effective Communication

Effective communication with healthcare agencies is vital for understanding patients’

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detailed medical history and fostering positive patient-staff interactions. It plays a crucial
role in decision-making for patient well-being (Garcia-Jorda et al., 2022).

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Potential Impacts of Ineffective Communications

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Ineffective communication can result in delays in timely treatment, health disparities,
increased treatment costs, and reduced patient satisfaction. These factors negatively
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impact patient outcomes and the quality of care (Raeisi et al., 2019).
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Barriers to Accurate Patient Information Transfer

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Barriers include insufficient staff, incomplete medical histories, and a lack of knowledge
about Electronic Health Records (EHR) technology. Overburdened staff may
compromise information accuracy, while incomplete medical records and EHR
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knowledge gaps can hinder seamless information transfer (Ilardo & Speciale, 2020; Tsai
et al., 2020).
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Strategy for Ensuring Comprehensive Understanding of Continued Care

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Effective planning, accurate information transfer, and follow-up sessions are crucial
strategies to ensure continued care. Collaboration with destination healthcare providers,
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complete discharge instructions, and understanding patient perspectives contribute to

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successful transitional care plans (Spencer & Singh Punia, 2020).

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Conclusion
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The transitional care plan is indispensable for transferring patients between healthcare
sectors, preventing complications, and improving overall patient care. Strategic
planning, effective communication, and comprehensive information transfer contribute
to successful transitional care, ensuring the well-being of patients like Mrs. Snyder.

References

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Borulkar, R., Dhande, P., & Dhande, P. (2022). Medication Reconciliation: A beneficial

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tool in patient safety 1 1. Bharati Vidyapeeth Medical Journal (BVMJ), 2(3).
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Chen, Y., Ding, S., Xu, Z., Zheng, H., & Yang, S. (2018). Blockchain-based medical
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Moghaddam, M. A.A., Zarei, E., Bagherzadeh, R., Dargahi, H., & Farrokhi, P. (2019).
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Promotion

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