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Transitional Care Plan


Institution Affiliation

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Transitional Care Plan

Patient Rebecca Snyder along with relatives and social laborer, was interviewed for the

admitting demographics. Rebecca Snyder is a woman of 56 years of age with a long term obese

Orthodox. Snyder has a past medical history of poorly controlled diabetes, hypertension,

hypercholesterolemia, anxiety, and obesity. She admits to the ED with protests of hyperglycemia

more than 230 for more than ten days, frequent urination, mild abdominal discomfort, malaise,

and dyspnea on exertion. As per the medical records, on date 5th August 2019, the patient was

determined to have Ovarian Cancer, and she was under medication for the condition. Therefore,

the paper aims to explore medical information and outline the nursing care plan for Rebecca


Snyder’s Case on Transitional Care Plan

Healthcare is advancing, and there has been a push to give care in the community rather

than protracted hospitalizations. These advances require a safe, effective, and ideal care plan for

the patient and the family. Naylor et al. (2017) state that transitional care alludes to the

coordination and congruity of medical care while developing a patient starting with one

healthcare setting, then onto the next healthcare setting or the patient’s home. Transitional care

includes the careful coordination and planning of the multidisciplinary group to guarantee a

smooth change for the patient and the family (DelBaccio et al., 2015). Drawing in and teaching

the patient and family concerning the patient’s complex healthcare needs and the requirement for

transitional care require a multidisciplinary team to keep away from disarray and superfluous


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Key Elements and Information Needed for Transitional Care

The Joint Commission(2015) recognizes the seven basics of the Transitional Care Model

(TCM) as essential in ensuring a safe transition from a healthcare facility to another. The

following are the seven approaches to enhance Snyder’s effective transitional care plan;

1. Leadership support: With the hospital, home health agencies senior leaderships, and

national policymakers becoming more conversant with the challenge of the transition, they have

become invested in finding solutions and the initiatives to be valuable in reducing readmissions

and achieving other favorable outcomes.

2. Multidisciplinary collaboration: For safe transition, the multidisciplinary arrangement

needs to commence the care, not just before the transition, and it also consists of involvement by

the patient and family/friend caregivers, as well as healthcare professionals, and more

importantly, the social workers(SW) and nurse case managers(CM) (Labson, 2015).

3. Early identification of patients at risk: High-risk patients for readmission are known by

aspects such as the number of prior admissions, high emergency department(ED) utilizers, health

literacy, social determinants of health (SDOH), confidence in self-care, complexity of the

medical condition, and discharge condition (Labson, 2015).

4. Transitional planning: Planning for care transition is more than the patient’s discharge

instructions; it involves effective coordination with all of the appropriate care providers

necessary to ensure that the patient is effectively transitioned home.

5. Medication management: Providing a medication list as part of a care transition is only

a start; educating patients and assessing their understanding of new medications will improve


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6. Patient and family action/engagement: Efforts to engage the patient and family are

ongoing education processes with the case management transition team. The team encourages

patient/family engagement, shared decision making and provides understandable instructions.

7.Transfer of information: Successful transfer of information between organizations,

patients, and referral sources is continuous by using remote monitoring and electronic health


Mrs. Snyder’s multidisciplinary team will need to collaborate care with her and the family

to make her end of life care known to the hospice facility. Encouraging patient and family

engagement will provide a clear understanding of Mrs. Snyder’s and her family’s wishes to

promote continuity of care and a smooth transition of care from one facility to another. Also

needed is the patient’s medication list, plan of care, family and church contact, and advance

directives to prevent a breakdown in care. These multidisciplinary interventions will ensure that

Mrs. Snyder positively transitions to the hospice facility for continued care.

Importance of each Key Element

1. With senior leadership support, this empowers the multidisciplinary team to

continually evaluate and improve patient transition processes.

2. The multidisciplinary approach now extends beyond the care conference to how care

transitions are made; how care is planned and provided in the home; and how patients,

caregivers, and staff are involved and educated.

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3. Early identification of patients/clients at risk and acquiring a better understanding that

assessing the risk of readmission is an essential first step toward prevention; evaluating and

understanding the patient’s state of mind, goals, concerns, and health literacy is another crucial


4. Planning for care transitions is more than planning a handoff; it is planning to ensure

continuous patient engagement, monitoring, and evaluation with a series of ongoing transitions

extending over the entire patient care period.

5. Compliance with medication regimens remains vital to optimal health outcomes, and

using tools to increase patient understanding, engagement, and patient-friendly medication lists,

are helping to improve adherence.

6. Patient and family action/engagement involves providers guiding patients toward

making their own decisions, instead of merely telling them what to do; once genuinely engaged

in their care, patients become physically, psychologically, and socially activated for the

betterment of their health.

7. Transfer of information using remote monitoring and electronic health records(EHR)

provides constant follow up with patients and offers effective handoffs and information transfer

for patients transitioning to other healthcare facilities or physicians (Labson, 2015).

Importance of Effective Communication

Engaging the patient and family and earning their trust will assist in effective

communication and smooth care transitions. Suppose the patient and family are made to feel

comfortable and included in their care. In that case, they will be more receptive to learning and

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participate in question and answer sessions involving new medications, testing, procedures, or

transfers to other healthcare facilities. Patients need to be presented with healthcare options and

be made to feel they are an active participant in their care, instead of feeling they are being told

what needs to take place(Naylor et al., 2017).

Barriers to the Transfer of Accurate Patient Information

There are numerous barriers to care when transitioning patients, and the healthcare team

must begin discharge planning at admission to acknowledge those barriers and overcome any

obstacles before discharge. Many HH agencies do not have access to EHR and rely on hospitals

to electronically fax the patient’s discharge bundles. If this is overlooked at discharge, a patient’s

care can be delayed in the home due to the agency awaiting hospital orders and care

recommendations. Another concern of incomplete or delayed information transfer is the

likelihood of medication errors or a delay in receiving medications.

Strategies to Ensure Accurate Care

Discharge planning will begin promptly with Mrs. Snyder by having a family meeting

and giving the family choices to the furthest limit of life care in their favored hospice facility.

Offering decisions and permitting the patient and family official help in smooth progress. The

multidisciplinary group will use the Continuity Assessment Records and Evaluation (CARE)

item set, created by the Centers for Medicare and Medicaid Services (CMS), to give legitimate

adequate communication to finish a successful transfer. When a facility is chosen, it is the

healthcare hospice group that precisely encourages Mrs. Snyder’s discharge prescription

rundown. The essential worry for Mrs. Snyder has torment control. Her agony should be tended

to and controlled with the right torment drug to give comfort and keep away from any necessary

transfers back to the clinic for torment control. In conclusion, the discharge outline needs settling

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with Mrs. Snyder, her family, and the multidisciplinary group all in agreeance with the discharge

plan. When discharge planning is finished, discussions need to happen with the accepting facility

to ensure they can oblige Mrs. Snyder’s social needs, recommended torment meds, and family

visits. When last care courses of action are set up and perceived by all healthcare suppliers, the

electronic transfer of discharge plans occurs, and a paper duplicate of the discharge is provided

with the emergency vehicle at the time of transfer.


This paper examines the significance of utilizing the Transitional Care Model to facilitate

safe, ideal, and collaborative discharge for patients being transferred to another healthcare

facility or home to utilize a home healthcare agency. This paper discussed the seven critical

components perceived by the Joint Commission for successful transitional care. The seven

critical components of transitional care were exploited by discussing Mrs. Snyder’s case in this

evaluation. However, these key components can be applied to any patient case.

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DelBoccio, S., Smith, D., Hicks, M., Lowe, P., Graves-Rust, J., Volland, J., Fryda, S., (2015).

Successes and challenges in patient care transition programming: One hospital’s journey.

OJIN: The Online Journal of Issues in Nursing, 20(3).

Labson, M. C. (2015). Adapting the joint commission’s seven foundations of safe and effective

transitions of care to home. Home Healthcare Now, 33(3), 142–146.

Naylor, M., Berlinger, N. (2016). Transitional care: A priority for health care organizational

ethics nurses at the table. Nursing, Ethics, and Health Policy, Special Report, Hastings

Center Report, 46(5), 39–42.


Naylor, M. D., Shaid, E. C., Carpenter, D., Gass, B., Levine, C., Li, J., Malley, A., McCauley, K.,

Nguyen, H. Q., Watson, H., Brock, J., Mittman, B., Jack, B., Mitchell, S., Callicoatte, B.,

Schall, J., & Williams, M. V. (2017). Components of comprehensive and useful

transitional care. Journal of the American Geriatrics Society, 65(6), 1119–1125.

The Joint Commission. (, 2015). Transitions of care: Engaging patients and families. Quick

Safety: An Advisory on Safety & Quality Issues.


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