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Transitional Care Plan

Learner’s Name

Capella University

NURS-FPX6610: Introduction to Care Coordination

Instructor Name

September 1, 2019

Transitional Care Plan

Transition care plans play an important role in facilitating the effective transition of

patients from one care setting to another. They are critical to the efficient and timely execution of

a broad range of transitional care services, which help promote the utmost safety and quality of

care for patients during transition. This paper will use the simulated case of Mrs. Snyder to focus

on key elements of transitional care, the significance of effective communication in transitional

care, the barriers that inhibit the transfer of information, and strategies to facilitate accurate

patient information transfer. Mrs. Snyder suffers from a terminal illness and has been scheduled

for a transition from a hospital to a hospice facility specializing in end-of-life care.

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

The key elements needed for facilitating qualitative transitional care are as follows:

• Medication reconciliation: It refers to the process of comparing a patient’s prescribed course

of medication against the medication that he/she has been taking until the point of transition

(World Health Care Organization, 2016).

• Communication of patient information to the destination care provider: It is important to

ensure that the destination care provider and the patient are provided with accurate, reliable,

and highly relevant patient information (Li et al., 2014).

• Patient education: Case managers should ensure that patients are duly educated on various

facets of health care such as self-responsibility toward care, better lifestyle choices, and

continuity of care (Naylor et al., 2017). For instance, instructing Mrs. Snyder to opt for

hospice care with continuous chemotherapy accompanied by intravenous steroids and

antiemetics is important to ensure that the transition of care is effective and improves her

outcomes.

• Individualized transitional care plan: It refers to an individualized care plan that includes

determination of the appropriate time for the patient to be discharged, the referral

arrangement to the destination care setting (World Health Care Organization, 2016), and

formulation of the patient’s needs, goals, treatment, medication, rehabilitation, and social

support (Li et al., 2014).

• Community support: Access to adequate community resources such as transportation

facilities, social support, health literacy, and outpatient care are critical to avoiding adverse

medical events such as hospital readmissions and deaths (Li et al., 2014).

• Ensuring continuity of care: This refers to the comprehensive implementation of the

transitional care plan. Case managers must ensure timely access of appropriate and

qualitative health- and community-based services, ensure timely exchange of information

between health care providers, and facilitate continuous access to the various sources of

health care (Naylor et al., 2017).

The information required to effectively transition Mrs. Snyder includes test results, a

discharge medications list, a course of hospitalization, patient counseling records, follow-up

plans (Li et al., 2014), social security and insurance information, medical history, advanced

safety risk measures, and detailed treatment and medication records for comorbid chronic

conditions.

Importance of Key Elements of a Transitional Care Plan

The significance of key elements of a transitional care plan is as follows:

• Medication reconciliation plays a crucial role in minimizing the occurrence of adverse drug

events and avoiding hospital readmissions (World Health Organization, 2016).

• The transfer of adequate, reliable, and accurate patient information to the destination care

provider is crucial to avoiding critical medical errors, minimizing the repetition of

medication procedures, and reducing health care costs. A study by Solet, Norvell, Rutan, and

Frankel (2005) estimates that 80% of critical medical errors arise from miscommunication

between health care providers during information transfer (as cited in Li et al., 2014)

• Patient education is important for ensuring that a patient adheres to discharge instructions

and medication, follows up with a care provider regularly (Mansukhani et al., 2015),

chooses the best course of care, and adopts a healthy lifestyle. A review study by Hibbard

and Greene (2013) highlights evidence-based studies that show direct links between patient

activation and healthy behavior, improved health care outcomes, and enhanced care

experiences (as cited in Li et al., 2014).

• The development of a comprehensive transition care plan is critical for the provision of

efficient and qualitative care. It helps set into motion the timely discharge of patients and

their transition to the most appropriate treatment and care setting.

• The importance of community resources can be substantiated by the fact that their

insufficiency has been the cause of hospital readmissions. A study by Englander and

Kansagara (2012) found that 40%–50% of hospital readmissions arose from social problems

and poor access to community resources (as cited in Li et al., 2014).

• Ensuring continuity of care plays a critical role in fostering trust in the sending care

organization in the patient and the destination care provider (Naylor et al., 2017). A study by

the American Society of Health-System Pharmacists and American Pharmacists Association

(2013) found that the Medication REACH program (a program that offers uninsured patients

free medicines) at Einstein Medical Center has a significant impact on hospital readmission

rates, with a 10.6% readmission rate for a cohort study group under the intervention and a

21.4% readmission rate for a control group not under the intervention. The findings from the

study serve as substantive proof for the positive impact of ensuring access to care continuity.

Potential Effects of Incomplete or Inaccurate Information on Care

A potential effect of transferring incomplete or inaccurate information is a delay in

treatment, which may result in adverse medical errors (Australian Commission on Safety and

Quality in Health Care, 2017). Inaccurate information may lead to wrongful treatment, which

may result in deterioration of health, or death in worse scenarios. A focused group study by

Allen et al. (2013), based on interviews with district nurses who dealt with older patients with

complex needs, concludes that poor information quality and untimely referrals result in treatment

delays and increased probability of adverse medical events (as cited in Australian Commission

on Safety and Quality in Health Care, 2017). Another potential effect of incomplete information

transfer is the increased likelihood for medication errors. In the absence of timely transfer of a

medication list from the hospital to the primary care settings, the general practitioner may fail to

consider changes in medication and may prescribe the wrong medication (Australian

Commission on Safety and Quality in Health Care, 2017).

Importance of Effective Communication

Effective communication is important to enable the transfer of relevant patient

information at the right time, which helps in facilitating informed, efficient care decisions by the

patient and destination care provider (Marder, 2018). Effective communication is critical in

forging a positive relationship between the patient and caregiver and, therefore, contributes in

increasing the patient’s trust level and adherence to care plans (Naylor et al., 2017).

Potential Effects of Ineffective Communications

A potential effect of ineffective communication is the inability of health care

management to ensure the swift, timely, and efficient admission of patients to the destination

health care setting. Consider an emergency case in which, because of the lack of accurate

transfer indication, a patient is transferred to an unqualified health care setting and later

retransferred to a health care setting. The uncalled-for delay in admission may have serious

health repercussions, including death (Pourasghar et al., 2016).

Ineffective communication may also lead to excessive costs for the patient. The absence

of a standard communication mechanism in the transfer of patient information may result in the

destination caregiver repeating laboratory tests, resulting in undue expenses (Pourasghar et al.,

2016). Another potential effect of ineffective communication is the lack of trust or a sense of

uncertainty among patients toward care providers because of the absence of transparency in

communication and poor care coordination (Pourasghar et al., 2016).

Barriers to the Transfer of Accurate Patient Information

A potential barrier to the transfer of accurate information from one care provider to

another, be it from one level of care setting to another, is the unplanned and off-hour transfer of

patients. Consider the case of Mrs. Snyder, who is transferred from a hospital to a hospice care

facility; the transfer of patient information hinges on the availability of a clear plan for post

discharge care, the timing of the transition, and the post discharge destination of patient. The

availability of the plan is critical to facilitating the accurate, relevant, and reliable transfer of

patient information.

An actual barrier reported by several experts involved in the transfer of patients is the

absence of a dedicated person responsible for the admission of patients from the sending

organization to the destination provider, which opens the chances of faulty information transfer

(Pourasghar et al., 2016). The lack of a dedicated person to handle Mrs. Snyder’s case may result

in the transfer of inadequate patient information or the mistaken transfer of another patient’s

information because of confusion in names.

A potential barrier to the accurate transfer of patient information is the absence of patient

information standards. The lack of a standard format for electronic health records, a standard

template for the information to be transferred, and a standard communication mechanism may be

a significant block to the transfer of accurate information.

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

Continued Care

To ensure that the destination care provider has an accurate understanding of continued

care for Mrs. Snyder, the following strategies can be adopted in a sequence:

a) The development and execution of a discharge plan. A discharge plan is a personalized plan

that includes the determination of the appropriate time for a patient’s discharge and adequate

provision of the post discharge care required by a patient (Alper et al., 2019). The execution

of discharge plan will ensure that Mrs. Snyder’s information is transferred at the right time

and that the destination care provider has enough time and information to understand her

case and make adequate arrangements for continued care. A systematic review study by

Sheppered et al. (2010) found that discharge plans were associated with improved patient

satisfaction and small declines in patients’ length of stay and readmission rates (as cited in

Alper et al., 2019).

b) Once the discharge plan is developed, it is important to ensure that medication reconciliation

for Mrs. Snyder is performed before the discharge medication list is prepared. Medication

reconciliation is highly critical to facilitate accuracy and completeness in the development of

the discharge medication list. The Joint Commission’s National Patient safety goals report

for 2015 found that discrepancies in the medication reconciliation process were associated

with medication errors, delay in the reception of medication, and higher rehospitalization

rates (as cited in Mansukhani et al., 2015). It is fair to say that medication reconciliation will

help facilitate the accurate transfer of Mrs. Snyder’s information, namely the discharge

medication list.

c) The case manager must ensure the development of an adequate discharge summary and its

successful transmission in a timely fashion. A discharge summary is critical to helping

clinicians from the receiving care organization form a holistic understanding of Mrs.

Snyder’s case instantly and, thus, contribute toward effective continuity of care. A

retrospective study by Hoyer et al. (2016) found that delay in the completion of discharge

summaries was associated with higher readmission rates in hospitals (as cited in Alper et al.,

2019). An effective mechanism to ensure that discharge summaries carry accurate

information is the use of standardized forms or templates (Mansukhani et al., 2015).

d) Lastly, it is important to ensure that Mrs. Snyder’s transfer records are accompanied by a

direct verbal exchange between the clinicians of the sending and receiving care providers. A

study by Jeffs et al. (2013) that was based on 31 interviews with clinicians involved in

transitional care found several clinicians advocating the exchange of verbal reports between

clinicians of the same level from the sending to the receiving organization.

Conclusion

In this paper, the author has successfully highlighted the various elements of a

transitional care plan. The simulated case of Mrs. Snyder, advised to transition to end-of-life

hospice care, has been used as a reference to highlight the importance and functionality of the

various elements of a transitional care plan. The transfer of accurate, reliable, and relevant

patient information is critical to facilitating the effective transition of care. The author has

comprehensively discussed the importance of the effective communication of patient information

and the implications of ineffective communication mechanisms. Finally, by carrying out

intensive research, the author has managed to highlight several evidence-based strategies to

facilitate accurate and efficient transfer of patient information.

References

Alper, E., O’Malley, T. A., & Greenwald, J. (2017, December 19). Hospital discharge and

readmission. https://uptodate.com/contents/hospital-discharge-and-readmission

Australian Commission on Safety and Quality in Health Care. (2017). Improving documentation

at transitions of care for complex patients.

https://www.safetyandquality.gov.au/sites/default/files/migrated/Rapid-review-

Improving-documentation-at-transitions-of-care-for-complex-patients.pdf

Jeffs, L., Lyons, R. F., Merkley, J., & Bell, C. M. (2013). Clinicians’ views on improving inter-

organizational care transitions. BMC Health Services Research, 13, 1–8.

https://doi.org/10.1186/1472-6963-13-289

Joint Commission International. (2018). Communicating clearly and effectively to patients: How

to overcome common communication challenges in health care [White paper].

https://store.jointcommissioninternational.org/assets/3/7/jci-wp-communicating-clearly-

final_(1).pdf

Li, J., Young, R., & Williams, M. V. (2014). Optimizing transitions of care to reduce

rehospitalizations. Cleveland Clinic Journal of Medicine, 81(5), 312–320.

https://doi.org/10.3949/ccjm.81a.13106

Mansukhani, R. P., Bridgeman, M. B., Candelario, D., & Eckert, L. J. (2015). Exploring

transitional care: Evidence-based strategies for improving provider communication and

reducing readmissions. P&T: A Peer-Reviewed Journal for Formulary

Management, 40(10), 690–694.

https://ncbi.nlm.nih.gov/pmc/articles/PMC4606859/

Marder, K. (2018, January 4). Saving lives: Effective healthcare communication empowers care

management. https://healthcatalyst.com/effective-healthcare-communication-care-

https://uptodate.com/contents/hospital-discharge-and-readmission

https://www.safetyandquality.gov.au/sites/default/files/migrated/Rapid-review-Improving-documentation-at-transitions-of-care-for-complex-patients.pdf

https://doi.org/10.1186/1472-6963-13-289

https://store.jointcommissioninternational.org/assets/3/7/jci-wp-communicating-clearly-final_(1).pdf

https://doi.org/10.3949/ccjm.81a.13106

https://ncbi.nlm.nih.gov/pmc/articles/PMC4606859/

https://healthcatalyst.com/effective-healthcare-communication-care-management

management

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 effective transitional care. Journal of the American Geriatrics

Society, 65(6), 1119–1125. http://doi.org/10.1111/jgs.14782

Pourasghar, F., Kavakebi, N., Tabrizi, J. S., & Mohammadi, A. (2016). Barriers to

communication and information exchange in patient transfer and its consequences.

Global Journal of Health Science, 8(12), 178–189.

http://doi.org/10.5539/gjhs.v8n12p178

World Health Organization. (2016, December). Technical series on safer primary care.

https://who.int/patientsafety/topics/primary-care/technical_series/en/

https://healthcatalyst.com/effective-healthcare-communication-care-management

http://doi.org/10.1111/jgs.14782

http://doi.org/10.5539/gjhs.v8n12p178

https://who.int/patientsafety/topics/primary-care/technical_series/en/

Key Elements and Information Needed for Ensuring High-Quality Transitional Care
Importance of Key Elements of a Transitional Care Plan
Potential Effects of Incomplete or Inaccurate Information on Care
Importance of Effective Communication
Potential Effects of Ineffective Communications
Barriers to the Transfer of Accurate Patient Information
Strategies to Ensure that the Destination Care Provider has an Accurate Understanding of Continued Care
Conclusion

Complete an interactive simulation in which you will make decisions about a patient’s end-of-life care. Then, develop a transitional care plan of 4-5 pages for the patient.

Introduction

Note: Each assessment in this course builds on your work from the preceding assessment; therefore, complete the assessments in the order in which they are presented.

To help reduce care fragmentation, a care coordinator working with patients who suffer from chronic illnesses must share important clinical information with stakeholders so everyone has clear shared expectations about their roles. Equally important, the care coordinator must work with the team to provide updated information to patients and their families and to ensure that effective transitions and referrals take place. This assessment provides an opportunity for you to assume the role of care coordinator and recommend appropriate transitional care for a terminally ill patient.

Relative to other facets of medical care, research directing efforts to improve care coordination has lacked rigor. However, many groundbreaking health care organizations have acknowledged the perils of poorly coordinated care models and applied interventions to improve these models. The objective of care coordination is to secure high-quality recommendations and transitions that aim for superior health care and guarantee that all involved providers, organizations, and patients have the necessary information and resources to make optimal patient care possible.

Note: Complete the assessments in this course in the order in which they are presented.

Preparation

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

· What are the likely outcomes of poor care transitions among providers and health care settings?

· Why is effective communication such a vital component of transitional care?

· Where are communication breakdowns likely to occur?

. Why?

. Have you seen or experienced such breakdowns in your own practice setting?

In the previous assessment, you conducted simulated stakeholder interviews and collected information for a plan of care for Mrs. Snyder. Now, seven months later, her condition has deteriorated.

To prepare for this assessment, complete the following simulation:

·
Vila Health: Care Coordination Scenario II
.

In this simulation, you will recommend appropriate end-of-life care for Mrs. Snyder and see how those recommendations can affect the lives of the patient and her family. Completing this exercise will help you develop a transitional care plan for Mrs. Snyder.

Note: Remember that you can submit all or a portion of your draft to Smarthinking for feedback before you submit the final version of this assessment. If you plan on using this free service, be mindful of the turnaround time of 24–48 hours for receiving feedback.

Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

·
Assessment 3 Example [PDF]
.

Requirements

Develop a transitional care plan for Mrs. Snyder.

Transitional Care Plan Format and Length

You may use a familiar transitional care plan format or template—for example, one used in your organization—or you may create your own. See the
Transition Care Plan Example [PDF]
provided.

· Format your transitional care plan in APA style; an
APA Style Paper Tutorial [DOCX]
is provided to help you. Be sure to include:

. A title page and references page. An abstract is not required.

. A running head on all pages.

. Appropriate section headings.

· Your plan should be 4–5 pages in length, not including the title page and references page.

Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your plan.

Developing the Transitional Care Plan

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your transitional care plan addresses each point, at a minimum. Read the Transitional Care Plan Scoring Guide to better understand how each criterion will be assessed.

· Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.

. Include elements such as emergency and advance directive information, medication reconciliation, plan of care, and available community and health care resources.

· Explain the importance of each key element of a transitional care plan.

. Identify potential effects of incomplete or inaccurate information on patient outcomes and the quality of care.

. Cite credible evidence to support your assessment of each element’s importance.

· Explain the importance of effective communications with other health care and community services agencies.

. Identify potential effects of ineffective communications on patient outcomes and the quality of care during the transition.

· Identify barriers to the transfer of accurate patient information from the sending organization to the patient destination.

. Consider barriers (actual or potential) inherent in such care settings as long-term care, subacute care, home care services, and home care with support, family involvement, et cetera.

. Identify at least three barriers (actual or potential).

· Develop a strategy for ensuring that the destination care provider has an accurate understanding of continued care.

. Consider the patient medication list, plan of care, or other aspects of the follow-up plan or discharge instructions.

. Cite credible evidence to support your strategy.

· Write clearly and concisely, using correct grammar and mechanics.

. Express your main points and conclusions coherently.

. Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.

· Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Portfolio Prompt: You may choose to save your transitional care plan to your ePortfolio.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

· Competency 1: Develop patient assessments.

. Assess a patient’s condition from a coordinated-care perspective.

. Develop nursing diagnoses that align with patient assessment data.

· Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.

. Evaluate care coordination outcomes according to measures and standards.

· Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.

. Determine appropriate nursing or collaborative interventions.

. Explain why each intervention is indicated or therapeutic.

· Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.

. Write clearly and concisely, using correct grammar and mechanics.

. Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Care Coordination Scenario II

·
Introduction

·
Challenge Details

·
Case

·
Interview with Rebecca and Avi Snyder

·
Treatment Recommendation

·
Case Update

·
Interview with Rebecca Snyder & Devorah Kaufman

·
Hospice Recommendation

·
Hospice Introductions

·
Hospice Facility Recommendation

·
Conclusion

Introduction

One of the most important roles in care coordination is the effective management of patient transition points. Finding the most appropriate facility for a patient—whether a rehabilitation facility, a nursing home, hospice, a home health care situation, or something else—is often a complicated manner. The care coordination team will have to consider the patient’s medical, financial, and social situation. The team will also have to be aware of any relevant regulations, and they need to keep in mind that regulations are subject to change. A facility that seems like an ideal match for a patient may not be feasible for any number of reasons.

In this activity, you will practice making recommendations in the role of a care coordinator who has to find appropriate care for a terminally ill patient. You will see the consequences of less-than-optimal decisions and will have the opportunity to correct these decisions. In the courseroom, you will have the opportunity to apply current regulations to the decisions that need to be made about this particular case.

After completing the activity, you will be prepared to:

· Problem-solve a care coordination scenario related to transitioning a patient to a new facility.

· Apply relevant regulations to a patient case related to transitions.

Challenge Details

Seven months have passed since Rebecca Snyder was diagnosed with ovarian cancer. Recent tests show that the cancer has spread. There is a strong possibility that chemotherapy might prolong her life, but Mrs. Snyder is in a good deal of pain and wants to go to hospice care. You are still working as an intern in the Case Management Department at St. Anthony Medical Center, and you have been assigned back to Mrs. Snyder’s case. You will have some decisions to make about what recommendations to make about her end-of-life care. The decisions you make can have a serious impact on Mrs. Snyder’s quality of life in her final days.

Rebecca Snyder Case

It looks like you have email from Denise McGladrey, your preceptor. Read the message, then review the documents below.

From: Denise McGladrey, Preceptor

Subject: Rebecca Snyder case

I’m sure you remember the Rebecca Snyder case that you worked on seven months ago. That was the first complex case that we assigned to you, and you did an excellent job sending Mrs. Snyder home with the resources and support she needed.

Mrs. Snyder is back in the hospital, and we are assigning this case back to you. Unfortunately, Mrs. Snyder’s ovarian cancer has spread. Her oncologist has recommended another course of chemotherapy, along with medications. The oncologist hopes this course of action could improve the quality of Mrs. Snyder’s life and also extend her life for another year.

However, Mrs. Snyder is in a good deal of pain and wants to discontinue treatment beyond palliative care. Her family is fighting her on this. As you may recall, Mrs. Snyder is very anxious about doctors and pain, and they think she is giving up treatment prematurely because she is afraid of it. They think she is not psychologically sound to make this decision.

As you know, this has been a challenging case, but I know you can handle it. As always, the CC team and I are available if you need to bounce some ideas off of someone.

Thanks,
Denise

Mrs. Snyder’s Electronic Medical Record

PATIENT INFORMATION

Patient Name: Rebecca Snyder
DOB: 04/24/1953
Address: 1375 Cadburry Lane, St. Louis Park MN 55402

Patient ID: #6700891
Gender: Female
Phone: (612) 776-8900

Insurance: Medicare
Primary Care Provider: Dr. Vereen, Vila East

Contact Permissions:
David Snyder, husband (952) 493-9302
Avi Snyder, son (952) 783-0021

PATIENT HISTORY

H&P: This patient is well known to me. Mrs. Snyder is a pleasant 57 year old obese Orthodox Jewish women newly diagnosed with Stage 4 ovarian cancer. PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. Recent falls. Decline in functional status.

Family Hx.
Mother: Alive. History of HTN, DM, Dementia, Stroke, PEG.
Father: Deceased. HX of MI, Colorectal CA
Sister: Alive. Recurrent breast CA. S/p Right mastectomy. New onset back pain with spine metastasis.

Meds on Adm: Lisinopril 40 mg po QD
Xanax 0.5 mg q 8 hr. PRN
Lantis 30 units of Q am SQ
Novalog 10 mg 3 times a day. SQ
Carboplatin IV q 30 days.

Neuro: A&O x3. C/O 10/10headache unresponsive to NSAIDS. Visual disturbance worsened. Worsening anxiety, difficulty sleeping, often irritable.

Respiratory: SOB with min exertion. In ED, sats 88% on room air. CXR reveals worsening pulmonary edema.

GU: c/o frequent urination with occasionally “not making it to the commode in the living room.” Occasional vaginal bleeding.

GI: Nausea and vomiting with chemo. Poor appetite. Increase in “bloated feeling” in abd. Admits to abd pain. Constipated. Recent report of dark colored stools.

POC: CBC, BMP, 10u insulin stat, check blood glucose q 1 hr., transfuse as necessary, Obtain brain MRI r/o brain metastasis, GYN/ONC consult.

ALLERGIES & MEDICATION

Allergies: Sulfa

Medication: #6700891
Metformin 1500 mg po bid
Lisinopril 40 mg po qd
Xanax 0.25-0.5 mg prn anxiety
Pravastatin 60 mg po bid
Chemotherapy: Cisplatin q 30 days per GYN/ONC
Motrin 800 mg po q8 hr.

LAB

CBC:
RBC: 2.8
HCT:22.8
HGB: 9.1
WBC: 2.1
MCV:72
MCH: 27
PLT: 56

BMP:
Glucose: 401
BUN: 33
Cr: 3.2
Sodium: 129
Potassium: 4.4
Chloride: 101
CO2: 22
Calcium: 19
Protein: 4.9

PRIMARY CARE NOTES

10/10/19:
Glucose remains elevated but is responding will to new insulin regime. Concerned about low Hct/Hgb-suspect Upper GIB. Occult blood in stools positive. Transfuse two unit PRBC’s.

GYN/ONC consult.

10/12/19:
Mrs. Snyder is a 57 year old Orthodox women newly dx. Metastatic ovarian cancer, Uncontrolled DM (401), GIB, metastatic brain mass.

PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity.

Dx: Metastatic ovarian cancer with brain mets, uncontrolled DM, HTN, obesity, anxiety, hypercholesterolemia, obesity.

Discussed diagnosis with Mrs. Snyder. Education provided about her secondary metastatic brain tumor. Family present in room. Answered questions.

POC: GYN/ONC consult, CM, SW, PT consult.

SOCIAL WORK

10/24/19:
Met with Mrs. Snyder after receiving call from PCP. Pt with new dx. Of metastatic ovarian cancer. Family very concerned about prognosis and are encouraging patient to continue with current treatment. Mrs. Snyder explained that she feels “awful” almost all of the time, and that “I just can’t do this anymore!”

Family at bedside. SW provided support and listened to family concerns.

POC: Discuss pt. care plan with PCP and CM. Team meeting

Goal: Safe transition of care.

10/24/19:
PCP: name
CM: name
Dietician: name
Physical Therapist: name
GYN/ONC: name

Team meeting discussion:
Here, we can write a discussion between team members. This will be more or less a conversation. We may want to have another team meeting and invite the patient and family. Please share your thoughts.

CASE MANAGEMENT

Met with Mrs. Snyder and her son Avi. Pt. and family with recent diagnosis of metastatic ovarian Cancer to brain. Pt presents with a 10/10 headache and has experienced recent falls at home without obvious injury. Purpose of the meeting was to discuss “next steps” as patients’ disease is progressing. Pt. stated that she does not want to continue chemo tx. Stating that it causing her undue pain and anxiety. Family expressed that they want mom around to watch her grandchildren grow. Encouraging patient to continue tx. As a cure could come anytime.

DIABETES EDUCATOR

Mrs. Snyder is a 57 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. Admitted to the ED with c/o recent falls, uncontrolled DM, and dark colored stools.

Met with Mrs Snyder to discuss nutritional needs. Pt. explained that she has a full feeling with bloating and is not hungry. She described that when she does eat or drink that she feels nauseous and experiences vomiting. Pt. has been on an over-the-counter antiemetic, but stopped taking it because it makes her eyes itch and makes her too drowsy to stay awake. Pt. stated she has not been following her diabetic plan of care-stating that it just “too much!” Stating that she will eat what she wants, whenever she wants to. Quite despondent. Appears sad and withdrawn.

Educated patient on self-care.

POC: Mrs. Snyder may benefit from a prescribed antiemetic. Will discuss with PCP. Obtain current weight as patient has stated she has lost at least 3 sizes over the last 7 months.

REHAB

10/13/19
Mrs. Snyder is newly dx. Metastatic ovarian cancer, to brain, Uncontrolled DM with blood glucose of 401, GIB, metastatic brain mass.

PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. Recent HX of multiple recent falls.

Mrs. Snyder lives a multi-level house with 8 STE. One flight of steps to second level. Bed and bath on 2nd level with first floor set up available. Resides with husband, debilitated elderly mother and 2 teenage sons. Household duties include meal preparation, driving and managing personal and business finances. Pt. requires assistance of 1 person to shop for groceries and to clean. Able to walk house hold distances by holding onto furniture. Requires minimal assistance with ADL’s. Requires additional time due to fatigue and recent SOB.

Pt. ambulated 5′ with min A due to unsteadiness. SOB. O2sats 88%. Placed on O2 2L. Sats improved to 93% after two minutes. Bed to chair transfer: Min A or one person and AD. Toilet transfer: Min A with one person and AD. Walked with a RW 8′ with one seated rest break.

LTG: Patient will ambulate safely 10′ with AD
STG: Pt will learn how to use a rolling walker when ambulating and with all transfers.

PROGRESS NOTES

SEE ABOVE

GYN/ONC

Mrs. Snyder is well known to me as an oncology patient. Mrs. Snyder is a 57 year old Orthodox women with a PMH of poorly controlled DM, HTN, anxiety, and obesity. She admits to the ED with c/o hyperglycemia, GIB, recent falls. Now dx. With a metastatic brain lesion. Radiologic studies confirm dx. Of metastatic brain lesion. At this time, chemotherapy appears to be stalling her ovarian cancer. Continued chemotherapy in conjunction with IV steroids and antiemetic’s may be an option for continues symptom control and pain management. Will discuss with family.

Interview with Rebecca and Avi Snyder

Mrs. Snyder is in her hospital room with her son, Avi. You have spoken to Avi before about Mrs. Snyder’s treatment, and he has been very helpful. You should meet with them to find out more about Mrs. Snyder’s current needs. Ask them as many questions as you like to get the answers you need.

Rebecca Snyder

Patient, St. Anthony Medical Center

Avi Snyder

Rebecca Snyder’s Son

Mrs. Snyder, how are you feeling?

Rebecca: Right this moment I’m doing okay because look at all this morphine they have me on!

Avi: Too much morphine in my opinion. It’s not good for her.

Rebecca: Oy, Avi, what does it matter if it’s not good for me? You should want your dying mother to be comfortable.

Avi: She isn’t dying yet. The doctor says she could live for a year or more if she gets more chemo. But she won’t listen.

Rebecca: It’s my time, Avi! I’m ready to go. And I’m sick of you and everyone else trying to keep me here when I’m in pain.

Why don’t you want to continue with chemotherapy?

Rebecca: I had a round of chemo and it was horrible! I threw up all the time and I was in so much pain. I refuse to go through that again.

Avi: But Mom, it will give you another whole year! At least!

Rebecca: Another year of what?

Avi: Look, my mother here is depressed and anxious. She’s terrified of pain. I don’t think she’s in the right state of mind to make a decision that’s going to end her life.

Rebecca: I most certainly am in the right state of mind!

Avi: My mother needs a psych consult.

Rebecca: How dare you speak as if I’m not in the room! I am an adult and I am perfectly capable of making my own decisions.

How are things going at home?

Rebecca: They’re okay. I can’t do everything that I used to do.

Avi: And that’s one of the main reasons she’s depressed. She’s used to doing things for everyone else.

Rebecca: I am not depressed. I’m just a little frustrated. There’s a difference.

Avi: She cleans, she cooks, she walks the dogs… she acts like nothing has changed. It’s no wonder she feels sick all the time when she won’t take a break. At least she finally relented and let us move her mother into a home.

Rebecca: I did. I don’t feel good about that.

Avi: It’s a very nice facility with kosher food and great nurses.

Rebecca: But it’s all the way on the other side of town. I don’t get to visit every day, especially now that I’m sick. I still feel like if I were a better daughter, I would have found a way to take care of my mother in my home.

Are you getting the help at home you need?

Rebecca: A lot of people have stepped in to help. Neighbors, people from the synagogue, cousins, you name it. It’s overwhelming.

Avi: And you need to let these people help you, Mom. She turns people away who want to do things like cook, which is ridiculous.

Rebecca: I can still cook for myself! I don’t want all these people around doing things that I’m perfectly capable of doing. It makes me feel guilty.

Avi: Guilty? Mom, you’ve been doing things for other people your whole life. It’s time for you to let other people take care of you.

Rebecca: I don’t want to be a burden! If I weren’t here anymore, people wouldn’t need to do these things.

Avi: Mom, stop talking like that! Do you hear her?

After you are discharged from the hospital, where would you like to go?

Rebecca: I want to go home. I am not going to die in some facility. I want to be surrounded by my family and die peacefully. And I want to be a burden to as few people as possible.

Avi: Mom, that’s fine eventually. But you’re not ready yet. There are still options for treatment.

Rebecca: There are no options that I can handle. No more pain, Avi, That’s all I ask. Send me with some good pain medications and let me fade away without suffering.

Avi: You are not in a psychologically sound position to make that decision.

Rebecca: Oy, Avi, you’ve gone meshuga! The whole family has gone meshuga.

What can we do to help you, Mrs. Snyder?

Rebecca: I just don’t want to be in pain anymore! And I don’t want to be a burden to my family. If the chemo didn’t hurt so much and make me so sick, then I would give it a try. Of course I would. Why wouldn’t I want to spend another year with my family? But there’s no way I can stand another round of that chemo. It was horrible! Please do what you can to get me sent home so I can die without pain.

What can we do to help you, Mr. Snyder?

Avi: Thank you for asking. I don’t know what to do anymore. I know my mother doesn’t have that much longer with us, but the doctor said there’s a really good chance she could live for a year or even more with another chemo treatment. If we could just find a way to get her through this treatment, then she could have months more to enjoy her last year. She deserves that. Please help me find a way to get through to her!

Treatment Recommendation

You need to make a recommendation about what the Snyders should do next. Choose one of these options.

Recommendation One

Strongly recommend that she go through with the chemo as recommended by the doctor. This could add a year to her life—and a quality year, once she completes the treatment.

Mrs. Snyder is furious. She gives you a piece of her mind and throws you out of her room. Later, when you try to see her again, she refuses.

Clearly this was not the best option. Mrs. Snyder has made up her mind that she doesn’t want to continue with the chemo. You should try another option.

Recommendation Two

Talk to the oncologist and other team members to find out if there are less uncomfortable chemotherapy options, and better ways to manage Mrs. Snyder’s pain and nausea.

Congratulations! You made an excellent decision.

You consult with an oncology nurse. The nurse comes to speak with Mrs. Snyder about medications that can be used to manage her pain and nausea. You also speak with the oncologist. Apparently Mrs. Snyder never told the oncologist how much she was struggling with side effects. The oncologist agrees to adjust the dosages of the chemo.

Mrs. Snyder is relieved. She didn’t know that these options were available, and she decides she wants to give another round of chemo a try.

Recommendation Three

Start investigating hospice arrangements—either home hospice or a facility. You can figure out the specifics later, but clearly Mrs. Snyder is a competent adult who has made this decision.

Denise: I’m going to stop you right there. You are right that Mrs. Snyder is a competent adult who can make her own decisions. Ultimately, if she wants to end her treatment, she can end her treatment. But are you sure there isn’t another course of action you could recommend first?

Recommendation Four

Send Mrs. Snyder to a psychiatrist for a recommendation to see if she is of sound mind to make this decision—and see if there anti-anxiety drugs that could help ease her through the fear of chemo.

Per your recommendation, Mrs. Snyder is sent for a psychiatric consultation. The psychiatrist concludes that she is more than capable of making her own decisions, even though she is depressed and anxious. The psychiatrist questions your decision to send Mrs. Snyder for a consultation.

You should try something else.

Rebecca Snyder Case Update

A day has passed since you met with Mrs. Snyder. It looks like you have email from Denise McGladrey, your preceptor.

From: Denise McGladrey, Preceptor

Subject: Rebecca Snyder case update

Bad news. It turns out that Mrs. Snyder’s cancer has spread more than was initially discovered. Her oncologist no longer recommends another round of chemotherapy, and instead recommends palliative care. Her prognosis is six months or less, so as you know, she is now eligible for hospice care.

Mrs. Snyder now needs help coordinating end-of-life care. You should meet with her as soon as you can. Good luck, and thank you again for all your good work on this case.

Thanks,

Denise

Interview with Rebecca Snyder and Devorah Kaufman

Mrs. Snyder is in her hospital room with her daughter, Devorah. Devorah is seven months pregnant. You should meet with them to find out more about Mrs. Snyder’s current needs. Ask them as many questions as you need.

Rebecca Snyder

Patient, St. Anthony Medical Center

Devorah Kaufman

Rebecca Snyder’s Daughter

How are you feeling today, Mrs. Snyder?

Rebecca: Well, the doctor just gave me six months to live. Otherwise, I’m peachy keen!

Devorah: They’ve adjusted the pain medications. So she’s feeling okay, at least for now.

Rebecca: I’m hungry. I could really go for a banana split.

Devorah: Mom, that’s not a good idea with your diabetes.

Rebecca: Oy, my diabetes. That’s what I want for my last meal, Devorah. A banana split.

Devorah: As you can see, she’s in a better mood. I think she actually feels relieved about the diagnosis.

Rebecca: I do feel relieved. Does that sound crazy? For months I’ve been worried about what’s going to happen next, and now I know.

What can I do to help you right now?

Rebecca: I just want to go home. I want to be in my own house surrounded by my family. That’s not too much to ask, is it?

Devorah: Of course not.

Rebecca: This palliative care… I can do that at home, right? You can send me home with pain medications? I don’t want to suffer.

Devorah: I’ve been reading about home hospice care. It definitely seems like the right option for our family. If we could have a home nurse to help out with some of the harder stuff, we can handle the rest.

If you choose home hospice, are there family members or others who can help?

Devorah: I can take care of my mother. And my brother Avi will help.

Rebecca: Oy, Devorahleh, I don’t want to burden you. There’s too much for you to do all by yourself, and Lord knows your father isn’t going to help. That baby will be here soon, and you have two other little ones at home to take care of.

Devorah: The baby won’t be here for another three months. And this pregnancy is going great—much better than the other two. My blood pressure hasn’t shot up in weeks. My mother-in-law has offered to help with the girls so I can take care of my mother.

Rebecca: But she works!

Devorah: But her schedule is flexible. At least most of the time it is.

Rebecca: And what if you have to go on bedrest? You did at the end of your other two pregnancies.

Devorah: That’s not going to happen, Mom. I feel great and my blood pressure has been close to normal. And Avi can help too.

Rebecca: Oy, Avi. Tell him to leave his liquor bottles at home.

Devorah: Avi’s been sober for months, Mom.

Rebecca: I wouldn’t say ‘months.’ When did he get out of rehab?

Devorah: He’s fine, Mom. And there’s a possibility that my aunt will come in from Florida and help out as well. She was here for a couple of weeks when mom first got diagnosed and that was a huge help.

Rebecca: Janet has health problems of her own now. Her back is really bad and I don’t think she’s supposed to fly.

Devorah: I’m pretty sure she can fly as long as it’s not too often. And there’s people from the synagogue who will be helping out too. We can definitely handle home hospice. We’ve been through worse!

How do you feel about hospice facilities?

Rebecca: They’re for old people who don’t have families. Not for someone like me.

Devorah: Hospice facilities seem like such lonely places. Why would anyone want to die in a facility like that when they could be in their own home?

Rebecca: Exactly. And I know that some hospices are actually pretty nice. But I don’t think I’d ever feel comfortable in a place like that. I want to be able to look at my old photo albums and put the twins to sleep at night. It’s bad enough that I’m not going to be able to be there for them anymore… [tears up] I’m sorry. I want to be able to spend as much time with my children and my grandchildren as I can.

Devorah: You will, Mom.

Rebecca: And my dogs. I know that sounds crazy. I couldn’t stand the thought of having those farstinkehneh beasts in my house until the boys just begged me. And now I can’t wait to get home and cuddle with them! It’s not like I could bring my dogs to a hospice facility.

Devorah: You don’t have to go to a hospice facility, Mom. You took care of your mother for years. It’s my obligation and my honor to do the same for you.

If you had to stay in a hospice facility, do you have a preference for a particular type of facility?

Devorah: I don’t even want to think of that possibility.

Rebecca: Well, we should discuss this, I think. What if you go on bedrest again?

Devorah: Mom…

Rebecca: Just in case, Devorah, we should talk about it. There’s a Jewish hospice facility not far from our house. I visited people from the synagogue there a few times. They have kosher food and they even have religious services on Friday and Saturday.

Devorah: But that place looks so sterile.

Rebecca: It’s not so bad inside. I mean, it’s certainly not my first choice. But if I have to go to a facility, that’s the one I’d want. I definitely couldn’t go to a facility that wasn’t Jewish. I wouldn’t be able to eat the food and I certainly wouldn’t feel comfortable.

Treatment Recommendation

Mrs. Snyder asks you for your recommendation. Should you recommend home hospice care, or recommend a hospice facility?

Recommendation One

Recommend home hospice care. It’s going to be a challenge for the family, but it’s very clear that’s what the patient wants, and she’s of sound mind to make that decisions.

You help the Snyder family with the financial arrangements, and Mrs. Snyder goes home for hospice. Unfortunately, problems arise immediately. Devorah’s mother-in-law is not able to watch her children as often as she needs. In addition, there’s a good possibility that she’ll have to be back on bedrest soon. Avi also doesn’t come by as often as he is needed, probably because he is drinking again. Mrs. Snyder’s sister is unable to fly in to help because of her back problems.

Without adequate help, Mrs. Snyder attempts to do the housework like she used to, which makes her exhausted and frustrated. Without adequate help with her medication, she’s been in a good deal of pain. Although she does not want to go to a hospice facility, Mrs. Snyder and her family agree that this is the right choice.

Recommending that Mrs. Snyder go home was not a good choice. Yes, that was what she wanted—and ultimately, you couldn’t have stopped her from doing so if she insisted. But there were a number of red flags that indicated she wouldn’t be able to get the care she needed at home, like her daughter’s pregnancy and her son’s alcoholism. Now Mrs. Snyder will have to be moved yet again to hospice care, and as a case manager, it’s important to limit the number of times a patient is moved. Transitions are stressful and expensive, especially for patients who are terminally ill.

You should try the other option.

Recommendation Two

Recommend that Mrs. Snyder go to a hospice facility. There are too many red flags to recommend home hospice care.

Rebecca: (adamant) No! That’s not what I want. I want to go home.

Devorah: I know it’s going to be a challenge to care for my mother at home. But we’re ready for the challenge. We’re a family, and we’re not going to send my mother away.

Recommendation Three

Continue to recommend that Mrs. Snyder go to a hospice facility.

You provide evidence to Mrs. Snyder and her daughter that a hospice facility would be a better choice. You ask them to imagine what would happen if Devorah had to go on bedrest, or if her mother-in-law were unable to watch the children, or if Avi started drinking again. You explained that families can still be very involved with their families and discussed all the resources that are available at hospice facilities.

Mrs. Snyder is very unhappy with this conversation and asks to think about it. Later in the day, she tells you she and her family have decided that the hospice is the right decision. Devorah and Avi tell you that they are relieved by this decision because they both doubt their ability to care for their mother adequately.

Recommendation Four

Change your mind. A facility might be a better option, but it’s not appropriate to keep pushing the issue.

Recommendation Five

Keep Mrs. Snyder in the hospital until a space opens up in the Jewish hospice.

Denise: I’m going to stop you. You can’t keep Mrs. Snyder in the hospital indefinitely. I understand that you want to honor her wishes and send her to a Jewish facility. But unfortunately, the health care system doesn’t allow us to keep a patient hospitalized when hospice care is a far more appropriate option. I know Mrs. Snyder won’t be happy, but you’re going to have to look for a hospice that can accommodate the needs of an Orthodox Jewish patient.

Recommendation Six

Send Mrs. Snyder home until a space opens up in the Jewish hospice.

Denise: I’m going to stop you. This is not a good choice for two reasons. First, you’ve already established that Mrs. Snyder cannot get the care she needs at home. Second, it’s important the limit the number of transitions that a patient makes as much as possible. Transitions are expensive and difficult for the patient. Now, it’s possible Mrs. Snyder will refuse to go to a non-Jewish facility and go home against your advice—and you can’t stop her from doing that. But you can try to find an appropriate facility and reduce the number of times she has to move.

Recommendation Seven

Look for another hospice that might be able to accommodate an Orthodox Jewish patient.

Mrs. Snyder is not happy with your recommendation that she goes to a non-Jewish facility, and she threatens to go home. However, you promise her that you will do your very best to find her an appropriate facility where she can get kosher food and feel comfortable. She reluctantly relents.

Hospice Introduction Interviews

Listen to the hospice introductions.

Kathryn Marcus

Fern Hill Center

What can you tell Mrs. Snyder about your facility?

Kathryn: Mrs. Snyder, I know you’d prefer to go to a Jewish facility, but we’d be able to work with you and your family to meet your needs, religious and otherwise. At Fern Hill Center, we really pride ourselves in communicating with patients to make them as comfortable as possible, physically and emotionally. End-of-life care is definitely not a one-size-fits-all experience. We’ve had patients before who require a kosher diet…. actually, we have one now. We have kosher food brought in for him from a nearby Jewish hospice facility. If you’d like, I can see if one of this patient’s family members wouldn’t mind calling you and letting you know how their experience has been. Oh, and I see from your photos that you have a couple of dogs? They’re beautiful… I just love Golden Retrievers. If they’re well-behaved, we can arrange for them to visit you. We’ve just started doing pet visits recently, and our patients love that.

Father Miguel Rivera

St. Francis House

What can you tell Mrs. Snyder about your facility?

Father Rivera: Mrs. Snyder, we’d love to have you at St. Francis! We welcome people from many faiths and have had many Jewish patients. People who are not Catholic often choose St. Francis because we are a place that celebrates faith and spirituality. We have both a Catholic and a non-denominational chaplain on staff, and of course your rabbi can visit as well. We’re also one of the top-rated hospice facilities in the state. I brought you some pictures… would you like to see? You would have a beautiful and private room with a lovely view of the courtyard, and your room would be right outside of our aquarium. We have several cats that live in our facility and we bring in dogs almost every day to visit with the patients. Like I said, we’ve had many Jewish patients, although I don’t recall if we’ve had any Orthodox Jewish patients before who required a kosher diet. But I’m completely sure we can accommodate your dietary needs! We accommodate vegetarians, gluten free folks, a bunch of different kinds of allergies…kosher food won’t be a problem.

Hospice Facility Recommendation

Should you recommend St. Francis House or Fern Hill Center?

Recommendation One

St. Francis House

Mrs. Snyder goes to St. Francis House. She is comfortable there, but it is not without its problems. The center brings in kosher food that is of poor quality and not very nutritious, so Mrs. Snyder’s daughter has to bring in better food for her to eat. Mrs. Snyder does like being in an environment that is focused on faith and spirituality, but she does have an unpleasant encounter with another patient who is determined to convert her to Christianity. The family is pleased with the palliative care at St. Francis, but they generally feel that communication is weak and that this is not the best place for an Orthodox Jewish patient.

See what would have happened if you had chosen Fern Hill Center.

Recommendation Two

Fern Hill Center

Mrs. Snyder and her family are very pleased with the care she receives at Fern Hill Center. The kosher food that is arranged for her is excellent. The staff does an outstanding job communicating with the family about Mrs. Snyder’s needs. As a result, the staff takes special care to help Mrs. Snyder with her anxiety. In addition, her dogs are welcomed into the facility as daily guests—and they provide comfort to other patients as well. After a few weeks, Mrs. Snyder’s daughter calls the hospital to thank you for recommending such an excellent facility.

Conclusion

You have completed the Vila Health: Care Coordination II activity. In this activity, you had the opportunity to speak with Mrs. Snyder and her children, and to make decisions about her end-of-life care. In the courseroom, you will further address issues related to this case, including current laws and regulations and how these relate to the case.

Running head: TRANSITIONAL CARE PLAN 1

Transitional Care Plan

Name

Institution Affiliation

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TRANSITIONAL CARE PLAN 2

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.

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

readmissions.

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TRANSITIONAL CARE PLAN 3

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

adherence.

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TRANSITIONAL CARE PLAN 4

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

records.

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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TRANSITIONAL CARE PLAN 5

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

step.

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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TRANSITIONAL CARE PLAN 6

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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TRANSITIONAL CARE PLAN 7

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.

Conclusion

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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TRANSITIONAL CARE PLAN 8

References

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).

https://doi.org/10.3912/OJIN.Vol20No03Man02

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.

https://doi.org/10.1097/NHH.0000000000000195

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.

https://doi.org/http://web.a.ebscohost.com.library.capella.edu/ehost/pdfviewer/pdfviewer?

vid=3&sid=ccf9a759-8710-4e8e-aab3-d5631bedee92%40sdc-v-sessmgr02

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.

https://doi.org/10.1111/jgs.14782

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

Safety: An Advisory on Safety & Quality Issues.

https://www.jointcommission.org/-/media/tjc/documents/newsletters/quick_safety_issue_

18_november_20151pdf.pdf

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TRANSITIONAL CARE PLAN 9

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