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Transitional Care Plan

This work provides a transitional care plan to support the resolution for Mrs. Snyder, a terminal patient, with a progressive worsening of her health status over the past seven months. Transitional care is crucial to reduce the gaps in client care and to ensure proper patient-centred care, especially during the late phases of an ailment. This is a care plan that intends to coordinate the actions of healthcare givers and organizations in response to Mrs. Snyder’s should overcome her wants, needs, and preferences. NURS FPX 6610 Assessment 3 encompasses important aspects like identification of the E&E info, advance directive, Meds review, and integration of CCM with healthcare resources in an attempt to align the context of Mrs. Snyder’s care with the interests of all the stakeholders involved. Such a multifaceted strategy is essential for enhancing patients’ outcomes, maintaining the patients’ follow-up, and honoring their and their families’ preferences during this vulnerable period (Coleman & Boult, 2021).

Key Plan Elements and Information

The privacy and confidentiality that is needed should entail that Mrs. Snyder’s emergency contact information and advance directives are accurate. As a part of advance directives, this includes appointing a healthcare proxy as well as telling her preferences on the use of life-sustaining treatments, resuscitations, and similar matters. These directives ought to be easily retrievable by all the clinicians participating in her treatment in order for her preferences to be understood and implemented in cases of crisis. Research has confirmed that advanced care planning documents can reduce the number of interventions and enhance patients’ quality of life in their last days (Teno et al., 2019).

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            NURS FPX 6610 Assessment 3 Medication management means prevention during the care transitions from one setting to another is vital because personally controlled medication errors and drug interactions are well-known. This process entails the compilation of a precise list of all the drugs that Mrs. Snyder is currently using, the dosage, and the time taken before the next administration. The list should be cross-checked with her current and past General Practitioner, all specialists, and the recent hospital discharge letters. To some extent, medication reconciliation has been found to lower the number of hospital readmissions and enhance the safety of patients (Gillespie et al., 2020).

NURS FPX 6610 Assessment 3 Desired Particular Plan

In the present case, a thorough evaluation of Mrs. Snyder’s plan of care entails her current medical status, ongoing treatment, and the final desired particular plan for care. This entails managing symptoms, giving terminal or hospice care, and addressing other psychosocial issues. The client’s management requires the involvement of a care team including physicians, nurses, social workers, and palliative care specialists to draw a holistic approach based on all the aspects of the client. The goal of every detailed plan is to keep the documentation as clear as possible so that what is continued and maintained is consistency in the delivery of care.

Considering the possible community and healthcare resources that can be applied to the situation means can significantly strengthen the help given to Mrs Snyder and her family. This comprises hospice, palliative care programs, home health aides, and other supporting groups/programs. Developing relationships with organizations for the patients and making sure that the referrals are made as soon as possible may assist in handling the signs and offering support. Engagement of community resources therefore enhances the quality of care to patients living with chronic disease hence enhancing patient satisfaction (Brumley et al., 2021).

Importance of Key Elements of a Transitional Care Plan

NURS FPX 6610 Assessment 3 Medical information concerning an emergency and an advance directive is useful so that the health practitioners can understand Mrs. Snyder’s preference concerning her treatment, especially at moments when she will be unable to express this decision independently. This information assists the healthcare providers to make proper decisions that are preferred by her and she does not want which increases her chances of avoiding unwanted invasive treatments. Lack of or incorrect information concerning emergency contacts or advance directives can cause ethical issues and the elaboration of care for both the patient and the family since in some cases the healthcare providers may be forced to deliver care that the patient had not wished for (Teno et al., 2019). Advance directives enhance the satisfaction levels of the patients and their families and also decrease the utilization of more intense care prior to death (Teno et al., 2019).

 Medication Reconciliation

            Medication reconciliation helps to avoid medication errors and adverse drug interactions, which are typical during patients’ transitions from one care setting to another. This process documents all the medications Mrs. Snyder is presently on together with their dosages as well as the time to which she is taking them. Effective medication reconciliation reduces the likelihood of patients receiving two therapies when they don’t need one, a patient is deprived of a medication that was essential for him or her, as well as situations where patients are put on two drugs that have a counteractive effect on each other. When a medicine list is insufficiently or improperly filled, there is a likelihood of serious and life-threatening adverse health outcomes, frequent hospitalizations, and worsening of the patient’s condition (Gillespie et al., 2020). NURS FPX 6610 Assessment 3 research demonstrates that proper medication reconciliation is highly appreciable in patients’ outcomes and safety as well as reducing costs due to the adverse drug effects mentioned above (Gillespie et al., 2020).

Key Implications of Missing or Inaccurate Information

Omission of vital information or the inclusion of wrong details in a transitional care plan has negative consequences on how patients are treated as well as their fate. Lack of accurate advance directives means that the healthcare providers may be forced to provide treatments that the patient does not wish therefore raising ethical implications as well as stress to the family members. Incorrect information about medications may lead to adverse effects such as contraindications or overdoses, sometimes causing severe deterioration of the patient’s health state, or readmittance to the health care system. A partial plan of care means effective care that lacks coherence and comprehensiveness, patients may miss out on time-sensitive treatments, and therefore the quality of care will be low. Moreover, failure to engage these resources will compromise symptom control and care, as well as other facets of the patient and family’s well-being. NURS FPX 6610 Assessment 3 imperative to devote sufficient time and attention to all the mentioned elements, as well as present extensive and exhaustive information, to provide Mrs. Snyder with comprehensive high-quality safe, and secure care that would contribute to positive changes in her health status and life.

Importance of Effective Communication

Introducing C-TSC would involve recognition of the principles of communication that are germane to patients’ transitional care. It enables all the healthcare personnel and community services that are involved in the care of Mrs Snyder to be in harmony with the best care that should be provided for Snyder. Effective communication minimizes the occurrence of misunderstandings, promotes continuity of care, and aids in the organization of global care requirements, particularly during the shift of the patient from one care environment to another (Kripalani et al., 2019). One of them is the coordination of care and sharing of important patient information including; records, current treatments, medication history, and patient preferences. This consistent and wide transfer of information minimizes the possibility of errors and missing information due to the patient’s transition from one care setting to another such as from hospital to home care or hospice (Verhaegh et al., 2021). Communication also helps the patient account for their caregivers to know their instructions in case they have a do-not-resuscitate order or the contacts of the next of kin in case of any complications.

Barriers to the Transfer of Accurate Patient Information

NURS FPX 6610 Assessment 3 is Common challenges to the timely and accurate exchange of patient information in LTC settings mainly consist of poorly developed communication technology frameworks and compliance with poor document management systems. It is also noted that some of these facilities may have limited EHR integration than the more intricate acute care facilities, meaning that records may have to be kept manually, with papers being the most common medium. This can cause barriers in the form of a lack of continuity, where a shift of caregivers occurs, and information passed may be partial, outdated, or misleading, (Vest et al., 2019). Also, frequent changes in staff members, or even over time, as well as differences in the training level among caregivers, affect the consistency of information recordings daily and their transfer, thus distorting the quality of passed information.

NURS FPX 6610 Assessment 3 Barriers in Subacute Care

Hospitals and other facilities in which subacute care is provided, including rehabilitation centers, long-term care facilities, and skilled nursing facilities, among others, operate in a challenging environment due to the complexity of patients’ medical conditions and treatment regimens. The process of transmitting data may experience certain difficulties due to the large amounts of information that are received and updated constantly with reference to patients. These settings also may be known to have inconsistent interactions between different caregivers such as specialists, the primary care attending doctor, and other therapy personnel. Poor collaboration can cause variations in patient’s prescriptions, care plans, and notes to the medical records (Bodenheimer & Sinsky, 2020).

 HOME CARE SERVICES CONSTRAINTS

The major problem of effective information exchange in-home care services is the pyramidal structure of care that is being delivered. Many of these practitioners are employed in home care setups and thus may physically be detached from the complete records of the patient at any one given time. NURS FPX 6610 Assessment 3 Interactions can be in the form of phone calls or emails, or through reports and these can be in sometimes inaccurate. Also, home care providers may not be using the same EHR systems as the hospitals or clinics, and therefore they are not effectively connected to the community of care (Osborn et al., 2020). Employees of home care organizations can, for example, be deprived of medical knowledge which is necessary to report changes in the condition of the patient or in the prescribed therapy to other healthcare providers like family caregivers who may be involved in home care.