Assessment 4: Transitional Care Interventions
Name
NURS-FPX6201: Leading in Nursing and Healthcare
Capella University
Instructor Name
July 2024
Transitional Care Interventions
Transitional care is crucial in ensuring that patients’ healthcare needs are adequately met as they move between different care environments (Parry et al., 2021). Hospitals must implement effective transitional care interventions to meet patients’ needs and reduce readmission rates (Sun et al., 2023). Such care transitions are essential for enhancing patient outcomes and conserving healthcare resources (Barbosa et al., 2023). This document seeks to present a summary of studies related to moving patients from hospital to home care, emphasizing programs at discharge that help reduce re-hospitalizations. By examining these research pieces, we can propose suggestions to better the approaches used in transitional care.
Annotated Bibliography
Abd, B. M., Maqbali, J. S., & Zakwani, I. (2023). Impact of clinical pharmacists-driven bundled activities from admission to discharge on 90-day hospital readmissions and emergency department visits. Oman Medical Journal, 38(6), e566. https://doi.org/10.5001/omj.2023.110
The study by Abd et al. (2023) explores how integrated care provided by clinical pharmacists from hospital admission to discharge can lower the rates of hospital readmissions. The focus is on the Medication REACH program, specifically aimed at Medicare fee-for-service beneficiaries. This program is structured to improve how medications are managed across various stages of patient care to avoid the typical pitfalls when patients return home and are at risk of mismanaging their treatment. Essential positions in this initiative encompass a care-transition pharmacist, a patient guide, and a care continuity coordinator, all collaborating to guarantee accurate medication management and patient comprehension of proper usage, thereby bridging any gaps in ongoing care.
The pharmacist plays a critical role by reviewing and optimizing the patient’s medication regimen and instructing both the patient and the care team using the teach-back method to ensure comprehension. After hospital discharge, the pharmacist coordinates with community pharmacies and handles necessary discussions with prescribers and insurance entities. This helps smooth the transition by addressing potential medication-related hurdles and suggesting more cost-effective medication alternatives. The bridge care coordinator then follows up within 72 hours after discharge, offering home visits and ongoing support to reinforce adherence to the care plan. Initial findings from a pilot study at a single Pennsylvania hospital indicate a reduction in 30-day readmission rates, suggesting the effectiveness of this detailed care coordination. Despite its promising results, the study acknowledges the need for further validation through larger-scale research across multiple sites to better generalize its findings.
Berthelsen, C., Møller, N., & Bunkenborg, G. (2024). Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilizing an umbrella review. Journal of Clinical Nursing, 33(2), 481–496. https://doi.org/10.1111/jocn.16913
The study investigates the effects of a targeted care approach for elderly individuals with numerous chronic conditions on their move from hospital settings to residential care. Utilizing an umbrella review, this study aggregates and analyzes data from various sources to evaluate the model’s effectiveness. It aims to enhance patient transfers from medical facilities to their residences to better patient health and minimize hospital return rates. The compilation of extensive data throughout this research aims to solidify evidence supporting the structured transitional care’s capability to handle the intricate health requirements of the elderly.
Findings from this evaluation reveal that this care model markedly improves outcomes for the elderly by ensuring ongoing and well-coordinated care after they leave the hospital. The model addresses key issues like managing medications, adhering to treatment regimes, and coordinating subsequent care visits, which are essential for patients with several health problems. The study emphasizes the necessity for a cohesive care process involving clear communication between healthcare providers, tailored educational efforts for patients, and consistent check-ins. This organized support not only aids in maintaining stable health conditions post-hospitalization but also helps reduce visits to emergency rooms and repeat hospital admissions, thereby highlighting an effective approach to enhance long-term health outcomes for seniors with complex medical conditions.
Lette, M., Stoop, A., Gadsby, E., Ambugo, E. A., Mateu, N. C., Reynolds, J., Nijpels, G., Baan, C., & Bruin, S. R. (2020). Supporting older people to live safely at home findings from thirteen case studies on integrated care across Europe. International Journal of Integrated Care, 20(4), 1. https://doi.org/10.5334/ijic.5423
The research based on the Safe Care at Home initiative aimed at improving how elderly patients care for themselves after leaving the hospital, focusing on those needing geriatric rehabilitation nursing care. This program provides thorough support from an advanced practice nurse who works closely with patients through two visits while in the hospital and two at home, along with follow-up phone calls. The APN plays a key role in guiding patients through their healthcare journey, helping them to ask important questions, understand their treatment plans, manage their medications, and notice important symptoms. This active involvement is backed by a systematic method of assessing the needs of patients soon after they enter the hospital and just before they leave, followed by home visits and consistent phone check-ups. This approach ensures ongoing, tailored care to help patients manage their health better and ease the transition from hospital back to home.
The study results show progress in improving the self-care of elderly patients, which could greatly lower the chances of them needing to return to the hospital. The APN’s role in creating a personalized health diary for each patient aids in better tracking and managing health conditions. However, despite these encouraging outcomes, the study’s limitation of only 25 participants from a single facility indicates a need for more extensive testing. This points to more research involving larger groups and various healthcare environments to verify whether the QUEST for Safe Care at Home program is effective and flexible enough for broader application. This model has significant potential to enhance elderly care and cut healthcare costs. Still, more comprehensive studies are crucial to prove its effectiveness on a wider scale and in different settings.
Provencher, V., Clemson, L., Wales, K., Cameron, I. D., Gitlin, L. N., Grenier, A., & Lannin, N. A. (2020). Supporting at-risk older adults transitioning from hospital to home: Who benefits from an evidence-based patient-centered discharge planning intervention? post-hoc analysis from a randomized trial. BMC Geriatrics, 20(1), 84. https://doi.org/10.1186/s12877-020-1494-3
The research explores how a discharge planning intervention focused on the patient’s needs affects at-risk older adults returning to their homes when they move from the hospital. Published in BMC Geriatrics, this research employs a post-hoc analysis to identify which groups of older adults benefit most significantly from these tailored interventions. This strategy is designed around developing discharge plans that are evidence-driven and tailored to the particular needs and medical conditions of the patients. The intervention aims to equip these seniors with the essential resources and support to manage their health autonomously and effectively once they return home, ultimately decreasing hospital readmissions and enhancing overall health outcomes.
The research outcomes indicate that the discharge planning intervention is particularly beneficial for specific groups of older adults, especially those facing particular health issues and social environments. The study points out the effectiveness of individualized discharge plans that consider each person’s health condition, living arrangements, and network of support, significantly boosting care success after hospital discharge. The findings stress the need for discharge plans to be customized to individual needs, facilitating easier transitions from hospital to home and aiding in sustained health management. This investigation supports the refinement and implementation of more detailed and effective discharge strategies vital for the elderly demographic, highlighting the necessity for health systems to implement patient-focused methods in their discharge protocols.
Wang, M., Hua, J., Liu, Y., Liu, T., & Liang, H. (2023). Application of a nurse-led transitional care program for patients discharged with T-tubes after biliary surgery. Nursing Open, 10(7), 4570–4577. https://doi.org/10.1002/nop2.1704
The study explores the outcomes of a transitional care program led by nurses for patients released with T-tubes following their biliary operations. The study highlights the necessity for customized post-surgical support that caters to the distinct needs of these patients. Managed by a dedicated nursing team, the program offers tailored educational sessions for patients, consistent health assessments, and structured follow-up procedures. These elements are intended to improve recovery speeds and reduce complications as patients move from hospital to home-based care.
The findings from this study suggest that the transitional care program successfully aids patients in navigating their recovery after biliary surgery, particularly in handling the intricacies associated with T-tubes. The program focuses on continuous education to help patients understand the proper care for their surgical sites, recognize signs of potential issues, and know when to contact healthcare professionals. This proactive management has led to lower rates of hospital readmissions and has notably improved patient satisfaction and overall health outcomes. The research highlights the critical role of specialized, nurse-driven transitional care in improving recovery trajectories for patients post-surgery, suggesting a framework that could benefit similar surgical recovery contexts to enhance patient safety and well-being.
NURS FPX 6201 Assessment 4 Transitional Care Interventions Conclusion
The reviewed studies underline the significant impact of tailored transitional care interventions in reducing readmissions and enhancing patient outcomes across various healthcare settings. These interventions, which range from specialized discharge planning to nurse-led follow-up programs, are crucial for addressing the diverse needs of patients, particularly the elderly and those with complex post-operative conditions. By focusing on personalized care plans, continuous education, and proactive healthcare management, these programs support patients in their recovery and contribute to healthcare delivery’s overall efficiency and effectiveness. The positive results highlighted across these studies advocate for the broader implementation and continual evaluation of such transitional care models to ensure they meet the evolving needs of patients and healthcare systems.
NURS FPX 6201 Assessment 4 Transitional Care Interventions References
Abd, B. M., Maqbali, J. S., & Zakwani, I. (2023). Impact of clinical pharmacists-driven bundled activities from admission to discharge on 90-day hospital readmissions and emergency department visits. Oman Medical Journal, 38(6), e566. https://doi.org/10.5001/omj.2023.110
Barbosa, M., Zacharias, M., Schönholzer, E., Carlos, M., Pires, L., Valente, S. H., Fabriz, A., & Pinto, C. (2023). Hospital discharge planning in care transition of patients with chronic noncommunicable diseases. Revista Brasileira De Enfermagem, 76(6), e20220772. https://doi.org/10.1590/0034-7167-2022-0772
Berthelsen, C., Møller, N., & Bunkenborg, G. (2024). Transitional care model for older adults with multiple chronic conditions: An evaluation of benefits utilizing an umbrella review. Journal of Clinical Nursing, 33(2), 481–496. https://doi.org/10.1111/jocn.16913
Lette, M., Stoop, A., Gadsby, E., Ambugo, E. A., Mateu, N. C., Reynolds, J., Nijpels, G., Baan, C., & Bruin, S. R. (2020). Supporting older people to live safely at home findings from thirteen case studies on integrated care across Europe. International Journal of Integrated Care, 20(4), 1. https://doi.org/10.5334/ijic.5423
Parry, C., Johnston, M., Johnson, C., Shifreen, A., & Clauser, B. (2021). Patient-centered approaches to transitional care research and implementation: overview and insights from patient-centered outcomes research institute’s transitional care portfolio. Medical Care, 59(Suppl 4), S330–S335. https://doi.org/10.1097/MLR.0000000000001593
Provencher, V., Clemson, L., Wales, K., Cameron, I. D., Gitlin, L. N., Grenier, A., & Lannin, N. A. (2020). Supporting at-risk older adults transitioning from hospital to home: Who benefits from an evidence-based patient-centered discharge planning intervention? post-hoc analysis from a randomized trial. BMC Geriatrics, 20(1), 84. https://doi.org/10.1186/s12877-020-1494-3
Sun, M., Liu, L., Wang, J., Zhuansun, M., Xu, T., Qian, Y., & Dela Rosa, R. (2023). Facilitators and inhibitors in hospital-to-home transitional care for elderly patients with chronic diseases: A meta-synthesis of qualitative studies. Frontiers in Public Health, 11, 1047723. https://doi.org/10.3389/fpubh.2023.1047723
Wang, M., Hua, J., Liu, Y., Liu, T., & Liang, H. (2023). Application of a nurse-led transitional care program for patients discharged with T-tubes after biliary surgery. Nursing Open, 10(7), 4570–4577. https://doi.org/10.1002/nop2.1704
