Transitional Care Plan 

It is important to consider transitions from one form of taking care of another as a part of the body and or patient’s overall plan so that such transitions can be as smooth as can be. These are critical to the efficiency of performing a multitude of transitional care services aimed at a high level of patient safety and care quality during transition (Allen et al., 2022). In this assessment, Mrs. Snyder’s example is used, to point to the features of transitional care, and stress the role of proper communication in contexts Watch Transitions in Care Around the Globe (Braz et al., 2022). This essay will continue the narrative of transitional care using the case of Mrs. Snyder to explore certain characteristics of the said process, demonstrate the significance of appropriate information exchange in this case, and indicate potential difficulties as well as possible solutions. Our next scene will occur in Mrs. Snyder’s house but shortly, she will be transferred to a special place called hospice because she is terminally ill.

Key Elements and Information Needed for Ensuring High-Quality Transitional Care 

Medication reconciliation can be simply defined as the process by which a patient’s current prescribed pharmaceuticals if any are compared with the previous ones up to the time of transfer to the new care setting (Costa et al., 2020).

Transferring patient data to the destination healthcare provider

It is essential to guarantee the identification of relevant, reliable, and very accurate information about the patient to the patient himself/herself and the intended care provider (Saragih et al., 2024).

Patient instruction

This is the responsibility of case managers to ensure that patients receive all the required information regarding health care including the continuities of treatments, how to lead healthier lives, and self-management of their care (Yoshimura & Sumi, 2022). For instance, it is important that Mrs. Snyder gets proper care coordination and increases her chances of getting better if she is advised to choose chemotherapy-assisted hospice care , injectable steroids as well as antiseptics. Medication reconciliation relates to the act of comparing the patient’s prescribed drug list to the ones that he or she has been using before the changeover period. Patient data is transferred to the destination healthcare provider: This means that only accurate, trustworthy, and extremely relevant information about the patient is given to the patient and the next level of carer (Braz et al., 2022).

Customized transitional care plan

This is a kind of personal care plan that reflects the patient’s requirements, aims, treatment, medicine, treatment, therapy, and care. It also decides when the patient is competent to be discharged; it also makes arrangements to have the patient transferred to the needed destiny care setting (Leeman & Toles, 2020).

Support from the community

The proposed predictors were adequate transportation, adequate social support, and adequate health literacy adequate outpatient treatment is pivotal to managing community influence within the domain and excluding unfavorable medical consequences such as readmissions and fatalities (Costa et al., 2020).

Maintaining continuity of care

It concerns the carrying out of the transitional care strategy in its entirety, as it lost its effective conceptual meaning with specific testing and measurement activities (Braz et al., 2022). It is the task of the case managers to promote the consumers’ continued engagement in the range of health resources; communicate effectively with other professionals; and promote the consumers’ timely access to appropriate and high-quality health and community services.

Records such as test results, a list of medications for discharge, a hospital stay, records of patient counseling and follow-up plans, records of Social security and insurance, higher level safety measures treatment, Medical history, and medication records for other co-morbid illnesses are among the necessary details to ensure the transition of Mrs. Snyder (Braz et al., 2022).

Importance of Key Elements of a Transitional Care Plan 

Medication reconciliation is critical in eliminating adverse drug events and avoiding hospital readmissions.

Thus, ensuring the transfer of sufficient, trustworthy, providing precise patient data to the healthcare professional at the destination is crucial for avoiding severe medical mistakes, reducing the duplication of pharmaceutical procedures, and decreasing healthcare costs (Michalski et al., 2023). It has been found in research that communication breakdown or lack of coordination between healthcare professionals regarding the transfer of information contributes to 80% of major medical mistakes.

Following up is important to ensure a patient adheres to medication and discharge instructions, selects the most appropriate treatment for a particular ailment, and maintains proper diet standards (Allen et al., 2022). A review study and the findings reveal that patient activation has a connection to healthy actions, better health, as well as enhanced experiences when receiving care. A proper transition care plan should be established to ensure the care executed is effective and of high standards (Saragih et al., 2024). It speeds up patients’ prompt admission to the best possible care and treatment facility as well as their timely discharge.

The existence of readmissions can be seen as proof of the importance of community resources because people were previously left without them (Costa et al., 2020). One study found that social factors and low availability of community service were involved in 40 percent to 50 percent of readmissions to hospitals. Intercept continuity of care is crucial in the process of developing trust between patients and the destination care organization and the sending care organization. In a study by the American Society of Health-System Pharmacists and the American Pharmacists Association, the authors described the Medication REACH program at Einstein Medica.

The Center that offers medications for the uninsured found out that it reduced readmission rates as a group of study cohort that received the intervention posted a readmission rate of 10% (Leeman & Toles, 2020). 21% higher than a control group has not engaged in the program. So, the findings of the study demonstrate much relevance to the issue of guaranteeing patients’ access to constant care.

Potential Effects of Incomplete or Inaccurate Information on Care 

It could be due to late therapy that information is passed to the wrong parties or incomplete information that could result in unfavorable medical mistakes. Such misinformation could lead to misdiagnosis or wrong treatment, therefore aggravating the health status of a patient, or even leading to death (Michalski et al., 2023). A focused group study of district senior nurses looking after elderly individuals with intricate requirements was done and the study found that poor information quality and delayed referral result in longer waiting times and increased medical vulnerability. The effect that is most likely to be experienced due to incomplete information transfer is that in a care chain medication errors may be more common (Michalski et al., 2023). If medication information is not transferred from the hospital setting to the GP within the shortest possible time then the general practitioner may not get to know that the dosages have changed and may prescribe the wrong medication.

Importance of Effective Communication

Thus, timely, suitable, and meaningful patient handover must be facilitated so that the patient and the intended destination care provider are enabled to make sound cost-conscious care choices (Toles et al., 2024). From the above analysis, it is obvious that the understanding of a positive between the patient and the caregiver entails good communication, in a bid to enhance the patient’s level of confidence in the caregiver and consequently compliance with the management plans.

Potential Effects of Ineffective Communications 

One potential outcome of poor communication is the inability of healthcare management to ensure admissions to the destination healthcare environment are prompt, timely, and effective (Leeman & Toles, 2020). Try to picture an emergency where the patient is taken to inappropriate facility and then is again transferred to a healthcare facility because the transfer indication is incorrect. Delay in admission to a hospital not justified may provoke fatal results as well as influence considerably the health state of a patient.

Patients can also be charged hiked prices due to bad communication between two related hospitals. If patient information is transferred without a laid down communication plan, then the caregiver at the receiving end may need to order laboratory results from the patient, at an extra cost (Saragih et al., 2024). Another potential outcome of ineffective communication is that patients withhold trust or feel confused towards the healthcare provider as a result of unclear and ineffective communication and poor care coordination.

Barriers to the Transfer of Accurate Patient Information 

Patients’ transfers at random times or during non-shift hours may disrupt efficient communication between different caregivers within the same level of care. In the case of Mrs Snyder who from a hospital is transferred to a hospice care facility, the definiteness of the care plan after discharge, the time of transfer, and the place where the patient is being discharged assumes significance regarding the transfer of information (Costa et al., 2020). The plan must be accessible to ensure the proper, accurate, and relevant transfer of patient data can occur in a trustworthy manner.

The absence of a designated individual in charge of admission from the sending organization to the destination provider has been identified by multiple experts participating in the patient transfer procedure as another significant obstacle. What is potentially damaging is that this state creates the possibility of inaccurate information transmission (Allen et al., 2022). The lack of someone to closely follow Mrs. Snyder increases the risk of the patient or, because of name similarity, transferring a wrong patient’s record with relatively little information.

Inadequate patient information templates may either delay the proper transfer of patient details or completely prevent it. However, there may be a problem of lack of a properly defined medium of communication, a standard structure of the message, or an electronic health record form.

Strategies to Ensure that the Destination Care Provider has an Accurate Understanding of Continued Care 

The following tactics can be used to make sure that the destination care provider is aware of Mrs. Snyder’s need for ongoing care: The following tactics can be used to make sure that the destination care provider is aware of Mrs. Snyder’s need for ongoing care: 

A discharge strategy during the discharge planning process. A discharge plan is a patient-specific plan that determines when the patient should be discharged and outlines the subsequent care that the patient requires (Michalski et al., 2023). The plan of discharge will ensure that Mrs. Snyder’s information is transmitted at the right time and ensure that the receiving care provider has adequate time and understanding of the patient’s status to be in a position to make the right arrangements for her subsequent care. A systematic review revealed that discharge planning was associated with increased patient satisfaction, a marginal decrease in patients, and a reduced readmission rate.

The discharge medication list should be done after the discharge plan has been developed but before the reconciliation of Mrs. Snyder’s medications is attained. Medication reconciliation is vital for the discharge medication list to be accurate and contain vital information (Braz et al., 2022). Variations in the medication reconciliation process have been associated with medication discrepancies, medication delay, and higher risks of rehospitalization, as indicated in the Joint Commission’s National Patient Safety Goals report. As it can be inferred, medication reconciliation should help in the proper transfer of Mrs. Snyder’s data or the discharge medication list.

The discharge summary is assumed by the case manager to be sufficient and it is his/her responsibility to ensure that it is transmitted on time (Leeman & Toles, 2020). For effective coordination of care as required in promoting continuity, a discharge statement is crucial in helping physicians of the receiving care organization to quickly and easily understand Mrs. Snyder’s case (Michalski et al., 2023). In the study, it was ascertained that readmission rates were higher when discharge summaries were delayed in completion. Conveying the information being presented in the discharge summaries is made easy by the use of standardized forms or templates.

Conclusion 

In conclusion, the different aspects of a transitional care plan have been explained with the help of the given hypothetical patient of Mrs. Snyder who was advised to change her plan to end-of-life hospice (Saragih et al., 2024). For continuity of care to occur effectively, information concerning a particular patient has to be transferred accurately, reliably, and where possible, relevant. The author has provided a piece of comprehensive information on how patient information needs to be communicated and also the implications of the wrong communication techniques. To sum up, the author has done an extensive study to elaborate several evidence-based strategies to practice effective and right communication with a patient to give them correct information.

References 

Allen, J., Hutchinson, A. M., Brown, R., & Livingston, P. M. (2022). Improving transitional care communication for older Australians from hospital to home: Co-design of the TRANSITION tool. Health & Social Care in The Community, 30(6), e4223–e4238. https://doi.org/10.1111/hsc.13816

Braz, P. G., Vila, V. D., & Neves, H. C. (2020). Strategies for case management in transitional care in emergency services: scoping review. Revista Brasileira De Enfermagem, e20190506. https://doi.org/10.1590/0034-7167-2019-0506

Costa, M. F. B. N. A. D., Sichieri, K., Poveda, V. B., Baptista, C. M. C., & Aguado, P. C. (2020). Transitional care from hospital to home for older people: implementation of best practices. Revista Brasileira De Enfermagem, 73Suppl , e20200187. https://doi.org/10.1590/0034-7167-2020-0187

Leeman, J., & Toles, M. (2020). What does it take to scale up a complex intervention? Lessons learned from the Connect-Home transitional care intervention. Journal of Advanced Nursing, 76(1), 387–397. https://doi.org/10.1111/jan.14239

Michalski, C., Jacquot, M. L., Rochat, S., Schmid, M. C., Maillat, S., Chevrey, N., Toledano, Y., Jeannot, J. G., Donzé, J., Bryant, D., & Mabire, C. (2023). Soins de transition entre l’hôpital et le domicile: pour quels patient-es ? [Transitional care from hospital to home: how to target the right population?]. Revue Medicale Suisse, 19(847), 2021–2025. https://doi.org/10.53738/REVMED.2023.19.847.2021

Saragih, I. D., Everard, G., Saragih, I. S., & Lee, B. O. (2024). The beneficial effects of transitional care for patients with stroke: A meta-analysis. Journal of Advanced Nursing, 80(2), 789–806. https://doi.org/10.1111/jan.15850

Toles, M., Colón, C., Hanson, L. C., Naylor, M., Weinberger, M., Covington, J., & Preisser, J. S. (2021). Transitional care from skilled nursing facilities to home: Study protocol for a stepped wedge cluster randomized trial. Trials, 22(1), 120. https://doi.org/10.1186/s13063-021-05068-0

Yoshimura, M., & Sumi, N. (2022). Measurement tools that assess the quality of transitional care from patients’ perspective: A literature review. Japan Journal of Nursing Science, 19(3), e12472. https://doi.org/10.1111/jjns.12472