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NURS FPX 6610 Assessment 3 Patient Care Plan

Assessment 3: Transitional Care Plan


Capella University

Introduction to Care Coordination  

Instructor Name

June 25, 2024

Transitional Care Plan

A transitional care plan is a vital framework that ensures continuity and quality of care for patients as they move between different healthcare settings (Ljungholm et al., 2022). It encompasses comprehensive information regarding the patient’s healthcare requirements, care directives, and available support options, facilitating seamless communication among healthcare providers. In this assessment, a transitional care plan is developed for Mrs Snyder, a 76-year-old individual with a condition of chronic obstructive pulmonary disease whose illness has recently deteriorated. This exercise involves making informed decisions about her end-of-life care, emphasizing the importance of effective communication, accurate information transfer, and strategic coordination with community resources to ensure high patient care and support for her family. This simulation provides practical insights into the complexities and critical elements required for successful care transitions.

Key Elements of a Transitional Care Plan

A comprehensive care strategy for Mrs Snyder must incorporate a thorough health assessment, end-of-life directives, pain control measures, effective communication, and psychological support. This strategy should thoroughly explain her requirements and meticulous supervision instructions, ensuring safe, high-quality transitional care and improved patient outcomes. Information on emergency protocols and advance directives is crucial to respect her end-of-life preferences and ensure appropriate crisis interventions (Li et al., 2021). Medication reconciliation is essential to prevent adverse drug interactions, maintain proper dosing, and ensure continuity of care through coordination with her pharmacy and healthcare providers.

The care plan should detail specific interventions and therapies tailored to Mrs. Snyder’s condition, such as oxygen therapy, pulmonary rehabilitation, and palliative care services, with clear goals for symptom management and quality of life improvement. Identifying and integrating accessible community and healthcare options, including home health services, respiratory therapy, assistance networks, and local healthcare facilities, will provide comprehensive support to Mrs. Snyder and her family. Effective communication strategies among primary care physicians, specialists, nurses, and family members are vital for coordinating care, sharing updates, and preventing information breakdowns (Sauer et al., 2023). 

The plan must include regular follow-ups and continuous monitoring to promptly address complications, adjust treatments, and provide ongoing support. Psychosocial support is also key, addressing Mrs. Snyder’s psychological and emotional needs to enhance her overall well-being. By incorporating these elements, the transitional care plan offers a detailed and comprehensive assessment of Mrs Snyder’s needs, ensuring secure, top-tier transitional care and enhanced patient results.

Significance of Essential Components in a Transitional Care Plan

An all-encompassing transitional care plan should incorporate several essential components to guarantee secure, high-quality care. Emergency and advance directive information is crucial as it guides healthcare providers during medical emergencies, ensuring that the patient’s wishes are respected. A study by Fleuren et al. (2020) has shown that advance directives significantly improve patient outcomes by aligning care with patient preferences. Medication reconciliation is another essential element, preventing adverse drug interactions and ensuring continuity of care. Research by Moges et al. (2022) highlights that medication discrepancies can lead to significant health complications, emphasizing the importance of accurate medication records. The care plan should include oxygen therapy, pulmonary rehabilitation, and symptom management and well-being goals. Research by Ljungholm et al. (2022) noted that complete or accurate information in the care plan can result in suboptimal treatment and increased hospital readmissions. 

Integrating community and healthcare resources and employing effective communication strategies ensures comprehensive support and continuity of care. According to Janagama et al. (2020), poor communication has been linked to adverse events and reduced quality of care. Regular follow-ups and continuous monitoring are necessary to promptly address complications, adjust treatments, and provide ongoing support. By incorporating these elements, the transitional care plan offers a comprehensive assessment of the patient’s needs, ensuring secure premium care and better patient results.

Crucial Role of Effectual Communication During Transitions

Effective interaction with healthcare and community service providers ensures a smooth patient-care transition. (Rojas et al., 2023). Effective communication coordinates care, shares patient information, and clarifies roles—poor communication risks fragmented care, medical errors, treatment delays, and adverse outcomes. According to a study by Ferreira et al. (2023), ineffective communication during care transitions greatly contributes to hospital readmissions. Clear and consistent communication is crucial for accurate patient information transfer, preventing adverse drug events, and ensuring continuity of care. Research by Blazin et al. (2020) found that medication discrepancies due to poor communication during transitions can lead to serious health complications. 

Effective communication helps to align the efforts of healthcare providers and community services, ensuring that patients receive comprehensive support tailored to their needs (Rojas et al., 2023). Effective communication ensures destination care providers understand patient needs, delivering high-quality care. Regular updates and feedback loops address emerging issues, maintaining consistent and coordinated care (Guttman et al., 2021). This approach enhances patient safety and improves overall care quality and patient satisfaction. 

Implications of Inadequate Communication on Patient Outcomes

Ineffective communication during care transitions can have severe implications for patient outcomes and the overall quality of care. One major consequence is the increased risk of medical errors, such as incorrect medication administration, due to incomplete or inaccurate transfer of patient information. According to a study by Jošt et al. (2022), discrepancies in medication information during transitions can lead to adverse drug events, significantly compromising patient safety. Inadequate communication often results in fragmented care, where healthcare providers lack a thorough grasp of the patient’s requirements leading to uncoordinated and suboptimal treatment plans (Guttman et al., 2021). This fragmentation can cause delays in necessary treatments and follow-ups, exacerbating patient conditions and potentially resulting in hospital readmissions.

Poor communication can diminish patient satisfaction and trust in the healthcare system. Patients and their families rely on clear, accurate information to make informed decisions about their care. When communication breaks down, it can lead to confusion, anxiety, and a sense of neglect, ultimately reducing patient engagement in their care. Research by Pournik et al. (2023) reports that communication failures are a primary cause of sentinel events, highlighting the essential need for strong communication strategies. Effective communication is crucial for maintaining excellent care and maximizing patient results during care transitions.

Obstacles to Precise Patient Information Transfer

The precise transfer of patient information is essential for effective care transitions, but several barriers can impede this process (Sauer et al., 2023). One significant barrier is standardized communication protocols across healthcare environments, including long-term care, subacute care, and home healthcare services. The lack of standardization can lead to discrepancies in patient information, resulting in miscommunications and potential treatment errors (Guttman et al., 2021). Another barrier is the limited use of interoperable electronic health records (EHRs). When healthcare providers use different EHR systems that cannot communicate with each other, critical patient information can be lost or inaccurately transferred, increasing the risk of adverse events.

Time constraints and high workloads can lead to incomplete documentation and hurried handoffs, compromising patient information accuracy (Sauer et al., 2023). While family involvement provides valuable support, it can also introduce inaccuracies if not properly aligned with healthcare providers. Standardizing communication protocols and ensuring EHR interoperability improve information accuracy (Li et al., 2021). Better staffing and workflow management enhance documentation and handoffs while involving family members with clear information mitigates miscommunications. These steps enhance care quality and patient outcomes.

Approach for Ensuring Accurate Comprehension of Ongoing Care

A comprehensive approach is crucial to guarantee that the receiving care provider fully comprehends the patient’s medication regimen, care plan, and follow-up schedule during patient-care transitions (Pournik et al., 2023). First, implementing a standardized handoff protocol, like SBAR, i.e., the Situation-Background-Assessment-Recommendation tool, can stimulate the clear and concise transmission of critical information. Research by Blazin et al. (2020) has shown that standardized handoff protocols improve information accuracy and reduce errors. Second, leveraging interoperable electronic health records (EHRs) allows seamless sharing of updated patient data across different healthcare settings, ensuring that the receiving provider can access the most current information. A study by Li et al. (2021) indicates that EHR interoperability significantly enhances care coordination and patient safety.

Involving a dedicated care coordinator to oversee the transition process can ensure that all care plan elements, including medication lists and discharge instructions, are accurately communicated and understood. This approach is supported by evidence from a study by Kinard et al. (2024), which found that the presence of a transition coach reduced readmissions and improved patient outcomes. Regular follow-ups and standardized protocols ensure accurate information transfer and care continuity, enhancing quality and outcomes.

NURS FPX 6610 Assessment 3 Patient Care Plan Conclusion

A well-structured transitional care plan is essential to maintain consistent and high-quality patient care transitioning between different healthcare settings (Sauer et al., 2023). By incorporating critical elements such as advance directives, medication reconciliation, detailed care plans, and effective communication strategies, healthcare providers can significantly improve patient outcomes (Ferreira et al., 2023). Addressing barriers to accurate information transfer and implementing robust strategies, such as standardized handoff protocols and EHR interoperability, further enhance the accuracy and integrity of patient data. These comprehensive approaches ensure patients receive consistent, high-quality care tailored to their needs, optimizing their overall health and well-being.

NURS FPX 6610 Assessment 3 Patient Care Plan References

Blazin, L. J., Sitthi, J., Hoffman, J. M., & Burlison, J. D. (2020). Improving patient handoffs and transitions by adapting and implementing i-pass across multiple handoff settings. Pediatric Quality & Safety, 5(4), e323. 

Ferreira, D. C., Vieira, I., Pedro, M. I., Caldas, P., & Varela, M. (2023). Patient satisfaction with healthcare services and the techniques used for its assessment: A systematic literature review and a bibliometric analysis. Healthcare, 11(5), 639. 

Fleuren, N., Depla, M. F. I. A., Janssen, D. J. A., Huisman, M., & Hertogh, C. M. P. M. (2020). Underlying goals of advance care planning (ACP): A qualitative literature analysis. Palliative care, 19(1), 27. 

Guttman, O. T., Lazzara, E. H., Keebler, J. R., Webster, K. L. W., Gisick, L. M., & Baker, A. L. (2021). Dissecting communication barriers in healthcare: A path to enhancing communication resiliency, reliability, and patient safety. Journal of Patient Safety, 17(8), e1465–e1471. 

Janagama, S. R., Strehlow, M., Gimkala, A., Rao, G. V. R., Matheson, L., Mahadevan, S., & Newberry, J. A. (2020). Critical communication: A cross-sectional study of signout at the prehospital and hospital interface. Cureus, 12(2), e7114. 

 Jošt, M., Knez, L., Mrhar, A., & Kerec, M. (2022). Adverse drug events during transitions of care: Randomized clinical trial of medication reconciliation at hospital admission. Wiener Klinische Wochenschrift, 134(3-4), 130–138. 

Kinard, T., Brennan, J., Johnson, S., Long, A., Yeatts, J., & Halpern, D. (2024). Effective care transitions: Reducing readmissions to improve patient care and outcomes. Professional Case Management, 29(2), 54–62. 

Li, E., Clarke, J., Neves, A. L., Ashrafian, H., & Darzi, A. (2021). Electronic health records, interoperability and patient safety in health systems of high-income countries: A systematic review protocol. BMJ Open, 11(7), e044941. 

Ljungholm, L., Edin, A., Ekstedt, M., & Klinga, C. (2022). What is needed for continuity of care, and how can we achieve it: Perceptions among multiprofessionals on the chronic care trajectory. Health Services Research, 22(1), 686. 

Moges, T. A., Akalu, T. Y., & Sema, F. D. (2022). Unintended medication discrepancies and associated factors upon patient admission to the internal medicine wards: Identified through medication reconciliation. Health Services Research, 22(1), 1251. 

Pournik, O., Mukherjee, T., Ghalichi, L., & Arvanitis, T. N. (2023). How interoperability challenges are addressed in healthcare IoT projects. Studies in Health Technology and Informatics, pp. 309, 121–125. 

Sauer, L. M., Resnick, B., Links, J. L., Garibaldi, B. T., & Rutkow, L. (2023). Information challenges associated with accessing and sharing patient information in disasters: A qualitative analysis. Health Security, 21(6), 479–488. 

Rojas, M. J., Teresa, C., Ramos, J. D., & Araujo, M. (2023). Barriers and facilitators of communication in the medication reconciliation during hospital discharge: Primary healthcare professionals’ perspectives. Healthcare, 11(10), 1495. 

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