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NURS FPX 6610 Assessment 3 Transitional Care Plan

Student Name

Capella University

NURS-FPX 6610 Introduction to Care Coordination

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Transitional Care Plan

Patient safety and quality of care are heavily reliant on transitional care, aiming to offer advanced facilities and services during the transfer of patients between treatment phases. Particularly crucial in chronic illnesses, continuous monitoring across treatment phases is imperative to prevent mortality, a task accomplished by a transitional care plan. This assessment explores the case of Mrs. Snyder, a 56-year-old patient with diabetes admitted to Villa Hospital for an infected toe. The focus is on discussing the transitional care plan for Mrs. Snyder and examining communication barriers that may impact the overall transitional plan (Korytkowski et al., 2022).

Key Elements & Information Needed for High-Quality Treatment

Patient care and safety improvements hinge on strict adherence to guidelines ensuring precision in diagnosis and effective tracking of patient medical records (Watts et al., 2020). Collecting Mrs. Snyder’s medical records is crucial for addressing her health issues comprehensively. These records not only aid in diagnosing specific health problems but also uncover other issues affecting overall health, such as depression, high blood pressure, and heart conditions (Chen et al., 2018).

In addition to medical records, understanding Mrs. Snyder’s medication list is vital for ensuring the appropriateness of her treatment. Medication reconciliation is necessary to determine the efficacy of her current medication and explore potential substitutes (Fernandes et al., 2020).

Obtaining information about emergency and advance directives is essential for providing patient-centered care. It helps in accommodating religious beliefs and understanding the patient’s treatment history from previous healthcare providers, minimizing potential conflicts (Dowling et al., 2020).

Patient feedback serves as a crucial element, offering insights into medical personnel behavior and the treatment process. Addressing patient concerns enhances the effectiveness of care and minimizes the risk of readmissions (Moghaddam et al., 2019).

Plan of Care and Education

Healthcare professionals play a pivotal role in tailoring care plans to meet individual patient requirements. This involves providing community-based healthcare services and facilitating rapid information exchange among healthcare professionals (Dyer, 2021).

Access to community and healthcare resources is vital for preventing adverse outcomes like hospital readmissions and mortality rates. These resources include mobility options, social support, health education, and outpatient treatment (Yue et al., 2019).

An insightful assessment of Mrs. Snyder’s needs requires comprehensive information such as medical test results, post-discharge prescriptions, time spent in the previous hospital, counseling documents, follow-up plans, social assistance and insurance coverage documents, current health condition, safety risk assessments, and detailed treatment and drug history related to chronic diseases (Humphries et al., 2020).

Importance of Key Elements of a Transitional Care Plan

Each key element in the transitional care plan is integral to improving patient care. Advance directive information aids in preparing for potential issues during treatment, while community and healthcare resources directly address patient concerns and needs (Schultz et al., 2021).

Medication reconciliation ensures accurate and safe administration of medications, reducing the risk of errors and adverse events (Borulkar et al., 2022). Patient feedback enhances the understanding of individual patient needs, contributing to more effective and patient-centered care (Fiorillo et al., 2020).

Healthcare professional training is essential for collaborative and culturally sensitive care. Education for patients like Mrs. Snyder is crucial for promoting self-management strategies and adopting a healthier lifestyle (Kaper et al., 2019).

Potential Effects of Incomplete or Inaccurate Information on Care

Transferring incomplete or inaccurate patient information can lead to treatment delays, complications, and adverse outcomes. Inaccurate medication information, for instance, may result in errors and increased mortality rates (Zirpe et al., 2020).

Importance of Effective Communication

Effective communication with healthcare agencies is vital for understanding patients’ detailed medical history and fostering positive patient-staff interactions. It plays a crucial role in decision-making for patient well-being (Garcia-Jorda et al., 2022).

Potential Effects of Ineffective Communications

Ineffective communication can result in delays in timely treatment, health disparities, increased treatment costs, and reduced patient satisfaction. These factors negatively impact patient outcomes and the quality of care (Raeisi et al., 2019).

Barriers to the Transfer of Accurate Patient Information

Barriers include insufficient staff, incomplete medical histories, and a lack of knowledge about Electronic Health Records (EHR) technology. Overburdened staff may compromise information accuracy, while incomplete medical records and EHR knowledge gaps can hinder seamless information transfer (Ilardo & Speciale, 2020; Tsai et al., 2020).

Strategy to Establish Absolute Understanding of Continued Care

Effective planning, accurate information transfer, and follow-up sessions are crucial strategies to ensure continued care. Collaboration with destination healthcare providers, complete discharge instructions, and understanding patient perspectives contribute to successful transitional care plans (Spencer & Singh Punia, 2020).


The transitional care plan is indispensable for transferring patients between healthcare sectors, preventing complications, and improving overall patient care. Strategic planning, effective communication, and comprehensive information transfer contribute to successful transitional care, ensuring the well-being of patients like Mrs. Snyder.


Borulkar, R., Dhande, P., & Dhande, P. (2022). Medication Reconciliation: A beneficial tool in patient safety 1 1. Bharati Vidyapeeth Medical Journal (BVMJ), 2(3). https://bvmj.in/journal/borulkar_2022.pdf

Chen, Y., Ding, S., Xu, Z., Zheng, H., & Yang, S. (2018). Blockchain-based medical records secure storage and medical service framework. Journal of Medical Systems, 43(1). https://doi.org/10.1007/s10916-018-1121-4

Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Junod Perron, N., Bajwa, N. M., Viet Vu, N., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & Nendaz, M. R. (2019). When team conflicts threaten the quality of care: A study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43–51. https://doi.org/10.1016/j.mayocpiqo.2018.11.003

Dowling, T., Kennedy, S., & Foran, S. (2020). Implementing advance directives—An international literature review of important considerations for nurses. Journal of Nursing Management, 28(6). https://doi.org/10.1111/jonm.13097

NURS FPX 6610 Assessment 3 Transitional Care Plan

Dyer, E. (2021). It’s about people: Caring agents and satisfied patients are key to a successful healthcare call center culture. Management in Healthcare, 6(2), 134–141. https://www.ingentaconnect.com/content/hsp/mih/2021/00000006/00000002/art00004

Fernandes, B. D., Almeida, P. H. R. F., Foppa, A. A., Sousa, C. T., Ayres, L. R., & Chemello, C. (2020). Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in Social and Administrative Pharmacy, 16(5), 605–613. https://doi.org/10.1016/j.sapharm.2019.08.001

Fiorillo, A., Barlati, S., Bellomo, A., Corrivetti, G., Nicolò, G., Sampogna, G., Stanga, V., Veltro, F., Maina, G., & Vita, A. (2020). The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review. Annals of General Psychiatry, 19(1). https://doi.org/10.1186/s12991-020-00293-4

Garcia-Jorda, D., Fabreau, G. E., Li, Q. K. W., Polachek, A., Milaney, K., McLane, P., & McBrien, K. A. (2022). Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study. BMC Health Services Research, 22(1). https://doi.org/10.1186/s12913-022-07590-6

Glans, M., Kragh Ekstam, A., Jakobsson, U., Bondesson, Å., & Midlöv, P. (2020). Risk factors for hospital readmission in older adults within 30 days of discharge – A comparative retrospective study. BMC Geriatrics, 20(1). https://doi.org/10.1186/s12877-020-01867-3

Humphries, C., Jaganathan, S., Panniyammakal, J., Singh, S., Dorairaj, P., Price, M., Gill, P., Greenfield, S., Lilford, R., & Manaseki-Holland, S. (2020). Investigating discharge communication for chronic disease patients in three hospitals in India. Plos One, 15(4), 0230438. https://doi.org/10.1371/journal.pone.0230438

Ilardo, M. L., & Speciale, A. (2020). The community pharmacist: Perceived barriers and patient-centered care communication. International Journal of Environmental Research and Public Health, 17(2). https://doi.org/10.3390/ijerph17020536

Kaper, M.

S., Winter, A. F. de, Bevilacqua, R., Giammarchi, C., McCusker, A., Sixsmith, J., Koot, J. A. R., & Reijneveld, S. A. (2019). Positive Outcomes of a Comprehensive Health Literacy Communication training for health professionals in three European countries: A multi-center pre-post intervention study. International Journal of Environmental Research and Public Health, 16(20), 3923. https://doi.org/10.3390/ijerph16203923

NURS FPX 6610 Assessment 3 Transitional Care Plan

Korytkowski, M. T., Muniyappa, R., Antinori-Lent, K., Donihi, A. C., Drincic, A. T., Hirsch, I. B., Luger, A., McDonnell, M. E., Murad, M. H., Nielsen, C., Pegg, C., Rushakoff, R. J., Santesso, N., & Umpierrez, G. E. (2022). Management of hyperglycemia in hospitalized adult patients in non-critical care settings: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. https://doi.org/10.1210/clinem/dgac278

Moghaddam, M. A.A., Zarei, E., Bagherzadeh, R., Dargahi, H., & Farrokhi, P. (2019). Evaluation of service quality from patients’ viewpoint. BMC Health Services Research, 19(1). https://doi.org/10.1186/s12913-019-3998-0

Raeisi, A., Rarani, M. A., & Soltani, F. (2019). Challenges of the patient handover process in healthcare services: A systematic review. Journal of Education and Health Promotion, 8(173). https://doi.org/10.4103/jehp.jehp_460_18

Schultz, B. E., Corbett, C. F., Hughes, R. G., & Bell, N. (2021). Scoping review: Social support impacts hospital readmission rates. Journal of Clinical Nursing. https://doi.org/10.1111/jocn.16143

Spencer, R. A., & Singh Punia, H. (2020). A scoping review of communication tools applicable to patients and their primary care providers after discharge from the hospital. Patient Education and Counseling. https://doi.org/10.1016/j.pec.2020.12.010

Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of electronic health record implementation and barriers to adoption and use: A scoping review and qualitative analysis of the content. Life, 10(12), 327. https://doi.org/10.3390/life10120327

NURS FPX 6610 Assessment 3 Transitional Care Plan

Watts, G. F., Gidding, S. S., Mata, P., Pang, J., Sullivan, D. R., Yamashita, S., Raal, F. J., Santos, R. D., & Ray, K. K. (2020). Familial hypercholesterolemia: Evolving knowledge for designing adaptive models of care. Nature Reviews Cardiology, 17(6), 360–377. https://doi.org/10.1038/s41569-019-0325-8

Yazdinejad, A., Srivastava, G., Parizi, R. M., Dehghantanha, A., Choo, K.-K. R., & Aledhari, M. (2020). Decentralized authentication of distributed patients in hospital networks using blockchain. IEEE Journal of Biomedical and Health Informatics, 24(8), 2146–2156. https://doi.org/10.1109/JBHI.2020.2969648

Yue, D., Pourat, N., Chen, X., Lu, C., Zhou, W., Daniel, M., Hoang, H., Sripipatana, A., & Ponce, N. A. (2019). Enabling services to improve access to care, preventive services, and satisfaction among health center patients. Health Affairs, 38(9), 1468–1474. https://doi.org/10.1377/hlthaff.2018.05228

Zirpe, K., Seta, B., Gholap, S., Aurangabadi, K., Gurav, S. K., Deshmukh, A. M., Wankhede, P., Suryawanshi, P., Vasanth, S., Kurian, M., Philip, E., Jagtap, N., & Pandit, E. (2020). Incidence of medication error in critical care unit of a tertiary care hospital: Where do we stand? Indian Journal of Critical Care Medicine, 24(9), 799–803. https://doi.org/10.5005/jp-journals-10071-23556

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