Transition Of Care Essay

Improved Essays
Many barriers to transition of care has led to failures and challenges during the discharge process of elderly patients. Transition of care can fail at many different levels between the preparation for discharge to when the patient has returned home. It is important to note that transition of care is a complex process that requires several key components for a successful transition. Failure of transition of care does not occur just at one point in the care, but generally at multiple points of the care. Multiple issues contribute to ineffective care transitions, including poor communication between inpatient and outpatient clinicians; medication changes during hospitalizations; inadequate patient understanding of diagnoses, medications, and follow-up needs; …show more content…
Unsuccessful transitions of care may be life threatening to the elderly population. In addition, patients admitted into hospitals may develop a dependence upon the hospital services that addressed their needs; however, upon discharge to home, patients and caregiver and expected to assume a self-management role with little support or preparation. At home, caregivers may not be able to provide the proper care necessary to ensure a safe transition.3 This can lead to negative impacts on the patient without support system to help with their transition.
The current health care system does not provide the important elements to effective transitions of care. Instead, it has produced challenges for patients and health care providers. One challenge is that many practitioners are deemed as “silos” of care, where there is limited

Related Documents

  • Improved Essays

    Introduction Transitions in life can be hard to adapt to if the person is ill-prepared, there are some transitions that can be expected and others which takes people by surprise. The transition from the home life to the hospital is often unexpected and most patients will have a hard time adjusting to the environment. In this paper I will be examining an episodic health challenge for one of the patients that I had the enjoyment of providing care to. An episodic health challenge is an abrupt change in life where one requires the assistance of nurses to provide care for him/her to facilitate recovery from chronic or severe illness. I will be using a pseudonym such as Mr.X to conceal the identity of the patient and to address his two son, one will be named Bob and the other Tom.…

    • 840 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    During the transition from the hospital to the home will be the time when the client is at the greatest risk for fragmented care (Lamb, 2014, p. 86). Even though the client has received the vital information needed to provide self-care, the client may lack the resources to care for himself and negotiate the transition between the settings. This change may cause the client to lose control of his condition and could lead to hospital readmission. As a result, the client should be assigned to a home health nurse and a community medical case worker to coordinate services needed following the discharge from the…

    • 901 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    In the event that a patient requires post-hospital assistance, the Via Christi Social Workers provides discharge planning service to any patient needing support. The Via Christi social work department creates a care discharge plan, considering the patient’s strengths, the patient’s current level of care, and patient current resources, such as available caregivers, if appropriate. Discharge plans can include, but not limited to, a referral to a home health care agency, a direct-admit referral to a long-term facility, a direct-admit to a rehabilitation facility, or help obtaining discharge prescription medications. Particular Interest Medical social work practiced in the hospital is particularly interesting because of the wide variety of specialized…

    • 871 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    INTRODUCTION Continuity of care is an essential objective promoted in nursing practice (Messam and Pettifer, 2009) and the indispensable component in achieving an effective transfer of patient’s care between health practitioners are often referred to as clinical handover (Evan et al., 2012). The term ‘handover’ is acknowledged as a moment of making a significant transition in maintaining patients’ continuity of care which involves a process whereby a patient is ‘handed over’ from one clinician to another (Anderson et al., 2010). In a hospital survey conducted in 2009 on patient safety-culture, 49% of the participants who were hospital staff reported that relevant patient care information where often lost during the process of shift changes…

    • 263 Words
    • 2 Pages
    Improved Essays
  • Decent Essays

    Throplasty: A Case Study

    • 212 Words
    • 1 Pages

    H. J., van Haastregt, J. C. M., van Hoof, S. J. M., Schols, J. M. G. A., & Kempen, G. I. J. M. (2016). Factors influencing home discharge after inpatient rehabilitation of older patients: a systematic review. BMC Geriatrics, 16(6). Retrieved from http://go.galegroup.com.prx-herzing.lirn.net/ps/i.do?id=GALE%7CA441824902&v=2.1&u=lirn50909&it=r&p=PPNU&sw=w&asid=66f5b40c8ab77b207e335922873b2f45 Krucik, G., MD. (2015, February 23).…

    • 212 Words
    • 1 Pages
    Decent Essays
  • Superior Essays

    Patient Handoff Case Study

    • 1088 Words
    • 4 Pages

    Background Information A literature review of patient handoff, and communication gaps of patient information during intrahospital patient transfers. The communication of complete and accurate patient information can be challenged, because of increasingly fast-paced and complex health care environments. Patient Handoff refers to, the process of transferring primary authority and responsibility for providing clinical care to a patient from one departing caregiver to one oncoming caregiver. Caregivers include attending physicians, resident physicians, physician assistants, nurse practitioners, registered nurses, and assistant care providers (Patterson, & Wears, 2010).…

    • 1088 Words
    • 4 Pages
    Superior Essays
  • Superior Essays

    Naylor and her interdisciplinary research team looking into ways to improve outcomes and reduce the costs of care for elders living in the community. Dr. Naylor and several collaborations have developed a transitional care model that employs advanced practice nurses (APNs) to provide hospital discharge planning and transitional care for a variety of vulnerable patient populations. This is a nursing practice and its benefiting the elderly for potential health benefits to patients at a lower total cost of care. This observation is being conducted in a pilot program in New Jersey, Delaware and Pennsylvania to evaluate the success of transitional care (Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwartz JS,…

    • 1208 Words
    • 5 Pages
    Superior Essays
  • Decent Essays

    Resource availability and caring for the patient at home. Loved ones may not have the capacity to care for the patient. There needs to be a designated caretaker at all times 24 hours around the clock to fulfill patient wishes, control pain. Patient has feared their pain may be unmanageable at home. The family may prefer to have their loved one care in a facility care base of the manageability of the patient and limited resources available.…

    • 160 Words
    • 1 Pages
    Decent Essays
  • Improved Essays

    Snfs In Nursing

    • 445 Words
    • 2 Pages

    When a patient is discharged from the hospital, under normal circumstances he or she will return to their respective home. But what happens when is one’s recovery becomes slower than expected? What options are available? Fortunately, skilled nursing facilities (SNF) exist to address this very issue.…

    • 445 Words
    • 2 Pages
    Improved Essays
  • Great Essays

    The Problem As stated by Flora, Parsons, & Slattum (2011), it would be beneficial for patients who are being transitioned from the hospital to another location, such as home or care facility, to have a transition coach, such as an advanced nurse, to educate the patients. He or she would provide…

    • 1934 Words
    • 8 Pages
    Great Essays
  • Improved Essays

    Care Systems Model Essay

    • 581 Words
    • 3 Pages

    Systems Model Current Care Delivery Model I am currently employed at a local Healthcare-Center that is certified as a level 3 Trauma Center with twenty-five-beds in the emergency room (ER). The staff in the ER consists of physicians, physician’s assistants, staff nurses, triage nurse, clinical manager (CM), assistant clinical manager (ACM), charge nurse, patient care assistants (PCA), unit secretary and a social worker. Other auxiliary staff from other departments such as laboratory, radiology, ultra sound and respiratory therapy also assist with patient care. There is also a house supervisor in charge of the nursing floors for the entire hospital. The hospital currently utilizes a Patient-Centered Care Model throughout all the nursing floors.…

    • 581 Words
    • 3 Pages
    Improved Essays
  • Decent Essays

    Discharge planning plays an important part in ensuring a smooth move from hospital to home. The aim of discharge planning is to limit costs, reduce the length of stay in hospital and minimise unplanned readmissions to hospital (Agency for Healthcare Research & Quality, 2015). A discharge plan should ensure that individuals are discharged at an appropriate time in their care. The discharge planning process must begin on admission and continue throughout the person’s hospital stay to ensure continuity of care when they are discharged home (Lees, L, 2013). Discharge planning discussion must include the physical condition of the person, types of care needed, whether discharge will be to a facility or home, what activities the person might need…

    • 259 Words
    • 2 Pages
    Decent Essays
  • Improved Essays

    First, the five-stage process of caregivers’ adjustment is adapted from the adaptation-coping model applied for patients with dementia of Dröes (1991) and Finnema et al. (2000) (Dröes et al., 2010, p. 144). Although the model of Dröes (1991) and Finnema et al. (2000) focuses on patients with dementia, not their family caregivers, their proposed model depicts a process with specific stages which concern coping with disabilities and an effort to preserve social and emotional balances.…

    • 497 Words
    • 2 Pages
    Improved Essays
  • Improved Essays

    Outpatient Care

    • 414 Words
    • 2 Pages

    As a pharmacist, they are expected to know drugs in depth, and be able to answer any questions that the patient may have about their medication. As stated in the abstract of the study, “Poorly executed transfers of older patients from hospitals to long-term care facilities carry the risk of fragmentation of care, poor clinical outcomes, inappropriate use of emergency department services, and hospital readmission. In this study, use of a pharmacist transition coordinator improved aspects of inappropriate use of medicines across health sectors.” This study, conducted by Maria Crotty and colleagues, showed that the use of pharmacists in the transitions of care is very beneficial, especially in the geriatric…

    • 414 Words
    • 2 Pages
    Improved Essays
  • Improved Essays

    Medication Reconciliation in the Hospital Setting The transition of patients from an acute care setting to a home setting is often challenging and stressful. It can be complex for the patient to understand the instructions for discharge and, more importantly, it can be challenging and dangerous when it comes to ensuring the patient understands the medication reconciliation process. Successful transition to home is multifaceted and depends partially on an accurate and complete overview of all medications with the patient. This is an imperative safety measure across the continuum of care (Ruggiero, Smith, Copeland, Boxer, 2015).…

    • 825 Words
    • 4 Pages
    Improved Essays