Nurse Transition Model

The changing environment surrounding the world of health care has begun to force hospitals to reevaluate how they provide care to their patients both while in a hospital setting as well as when they return home. At one time the hospital was merely only held responsible for the treatment patients while they were in house. This sometimes led to increased length of stay, or patients being sent for expensive procedures, which were not necessary but provided more profit for the hospitals. However, now with the ever present threat of fines from federal health insurance providers, Medicare and Medicaid, the extent to which post-hospital patient care is provided has taken on a vital importance which hospitals must observe so they avoid the associated …show more content…
The goals of a Nurse Practitioner led transition approach would include medication reconciliation, early identification of problem, providing further patient education in a more intimate home setting which would include management of treatments (i.e. dressing changes, wound care, scheduling of medications), assessing the home safety and ability to perform ADL activities. The Nurse Practitioner would then use this information to refine and modify the patient’s care at home to be appropriate for their level of activity and mentation and all pertinent information would be communicated back to the patient’s healthcare provider. If a patient is found to unable to care for himself or herself, once the NP has made these assessments, the patient could be found as a candidate for home nursing care, as well as other intervention that can be provided such as physical …show more content…
On top of the medication teaching provided by the nurses, as well as use of teach back methods, the inclusion of a education program provided to the patient by pharmacists would be another highly valuable tool for the patient and to decrease their likelihood of being readmitted. These kinds of ancillary programs would not necessarily be only provided by the hospital but may also be provided to the community by independent corporations. “Walgreens offers Well Transitions, which has community pharmacies, working onsite in hospitals in collaboration with hospital pharmacists and clinical health care team members, to align prescription therapy, deliver discharge medications to the bedside counsel patients about their drug therapy, and follow up with patients post discharge.”