Hello Everyone, In my research about transitional care, I learned that it is focused on coordination and continuity of care within older adults during their transfer between locations or new care providers (Weeks et al., 2016). Transitional care providers are commonly referred to as “health navigators” and communicate with various colleagues at multiple sites to ensure that these transitions occur smoothly, safely and effectively (Weeks et al., 2016). Some research studies have shown that the benefits of transitional care include “reduced unnecessary hospital admissions, readmissions and premature nursing placements” (Weeks et al., 2016). This is important to note because another report I found mentioned how the constant movement of patients
(especially Medicaid beneficiaries) from the hospital setting back to the community costs approximately $15 billion in Medicare spending (Naylor, Aiken, Kurtzman, Olds & Hirschman, 2011). Under the ACA, the community-based transitions program was created and provides funding to health systems and community organizations that provide at least one type transitional care service to high risk Medicare beneficiaries, which has had a positive effect on hospital readmissions (Naylor et al., 2011). Success of care transitions is also dependent on holistic interventions involving discharge planning and at home follow up and support (Allen, Hutchinson, Brown & Livingston, 2014). Overall, more research and evidence in quality of transitional care as it relates to effectiveness, timely, safe, equitable and patient/family centered is needed (Allen, Hutchinson, Brown & Livingston, 2014). Interestingly, another article I found on care coordination mentions that despite the notion that care coordination is linked to improve outcomes and lowered costs, there is a lack of evidence-based research that justifies this (McWilliams, 2016). Studies on programs designed to improve coordination and care management showed minimal to no cost savings, and reasons for this include lack of interventions to ensure timely access to care, high number of patients to treat, and how to offset costs of care coordination from the additional costs of using information technology, personnel and other resources (McWilliams, 2016). One argument this article mentions is that “an overemphasis on care coordination as a cost-cutting strategy could divert attention and resources from the development of approaches that more effectively eliminate provision of low-value services” (McWilliams, 2016). Given these findings, more research and evidence are needed to find ways that improve care, costs and quality.
Interprofessional teams in health care are considered to be one of the best approaches to improve patient outcomes. Interprofessional teams provide the means to integrate patient care with input from many different professional disciplines (Rose, 2011). Nurses are an important part of the interprofessional team, since they are often the team member that is closest to the patient (Miers & Pollard, 2009). I recently participated in a team that developed a work flow for daily readmission rounds. The team was interprofessional, the hospitalist, who was an APRN led the team. There was the case manager and the primary nurse who were both RN’s. The team also consisted of a resident, pharmacist, nutritionist, physical therapist, and social worker.
According to Statistics Canada Report 2013, “life expectancy in Canada is one of the highest in the world” and it is expected to grow, making the aging population a key driver to our health-systems reform. By 2036, seniors in Canada will comprise of twenty five per cent of the population (CIHI, 2011). Seniors, those aged 65 years and older are the fastest growing population in Canada. Currently there are approximately 4.8 million Canadians aged 65 or greater. It is projected that this number will increase to 9 to 10 million by 2036 (Priest, 2011). As the population get aged the demand for health care and related services are expected to increase. Currently, the hospitals in Ontario are frequent faced with overcrowding emergency departments, full of admitted patients and beds for those patients to be transferred to. It has been reported that 20% of the acute care beds in the hospital setting are occupied by patients that do not require acute hospital care. These patients are termed Alternate Level of Care (ALC). ALC is “When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in this care setting (Acute, Complex, Continuing Care, Mental Health or Rehabilitation), the patient must be designated Alternate level of Care at that time by the physician or her/his delegate.” (Ontario Home Care Association, 2009, p.1).
Knight, K. E. (2011). Federally qualified health centers minimize the impact of loss of frequency and independence of movement in older adult patients through access to transportation services. Journal of Aging Research, 1-6. doi:10.4061/2011/898672
Kralik, D., Visentin, K., & Van Loon, A. (2006). Transition: a literature review. Journal Of Advanced Nursing, 55(3), 320-329. doi:10.1111/j.1365-2648.2006.03899.x
I feel that TANF is a useful program, because it allows people to have access to things that they would not generally have. It also allows for the opportunity to receive actual help in bettering other people’s lives. I wish more programs like this existed and offered not only monetary support, but also childcare and education assistance. If more programs like TANF existed there would be more opportunity to better one’s self and less of a sense of being trapped in a poor economic condition.
Health, C. (2009). The Continuity of Care Changing the Landscape of Healthcare Information. Corepoint Health, http://www.corepointhealth.com/sites/default/files/whitepapers/continuity-of-care-document-ccd.pdf.
Patient navigation is an excellent program that expanded since its establishment. However, it is a program that is only offered to cancer patients. In this paper, I will discuss the implementation of the patient navigation program at the three major hospitals in Albuquerque, which include University of New Mexico Hospital (UNMH), Presbyterian and Lovelace Women’s Hospital and then discuss the future of patient navigation, which may mean expansion of services to patients who are affected with other chronic diseases.
Transition is the process of changing from one state to another. Transition is the core of discipline in nursing ( Schumacher & Meleis, 1994, p.120). One particular transition listed in the Conceptual Curriculum Model is Health-Illness. Health can subjectively be defined as a state of optimal well being while illness can be defined as a sickness having a negative affect on the body. Two of the four aims of nursing are to promote health and prevent illness. In order to be successful in meeting these aims, a nurse will use knowledge, skills and critical thinking. (Taylor, 2011, p. 9). Health Illness can include acute or chronic illness (Murphy, 1990, p.3) There is a correlation between health illness and program outcomes. In order to promote health and prevent illness, a nurse must care for patients,...
As a provider of care an AD nurse uses a systematic approach in all areas. Using the process of assessment, analysis, implementation, and evaluation the nurse is able to be consistent and efficient when providing care. As a provider of care the AD nurse must assess a patient’s health status, gather medical history, plan, coordinate, and implement care. The nurse will use continual assessment and evaluation in order to ensure the best outcome for the patient. The AD nurse must develop a therapeutic relationship with the patient in order to effectively treat and provide advocacy. During my clinical rotation I was able to implement many of these steps. I provided daily physical assessments, took vital signs, implemented hygiene care, fed patients, re-positioned patients and changed bed linens. During each shift I was respons...
Nursing assistants work in many types of settings including nursing homes, hospice, mental health centers, assisted living residences, home care agencies, hospitals, rehabilitation and restorative care facilities (Sorrentuino & Remmert, 2012). There are many types of Long-term care centers. For this paper, I will focus on the long-term care centers often referred to as nursing homes. These LTCs are "licensed facilities that provide extended care for individuals who do not require the acute care provided in a hospital but who need more care than can be given at home" (U.S Department of Health And Human...
In order to increase patient satisfaction by providing a more efficient method of continuity of care, Clark and the staff nurses proposed an innovative care delivery model that placed a Patient Care Facilitator (PCF) in charge of about 12 patients each (Clark, 2011). She further explains that each PCF will head 2 Registered Nurses (RN) and a Certified Nursing Assistant (CNA) for the same group of patients (Clark, 2011). Staffing plays a key role in continuity of care by having the same nurses staffed to the same group of patients with the PCF available 24/7.
In their research study they tested the use of “a patient-monitoring system designed to optimize patient-turning practices” (Pickham et al. 2016), this system involves sensors being attached to patients and allows the nurses to determine “the patient 's current position and time-to-next-turn” (Pickham et al. 2016). As a result of this evidence based practice, these researchers were able to use their clinical expertise to gather patient data in order to improve nursing practice, as a result “After implementation of the system, compliance and patient turning was reported to have increased significantly from 64 to 98 %” (Pickham et al. 2016), therefore this is definitely something that could assist all nurses in helping the to perform their jobs more proficiently. However since this kind of monitoring is not currently used in all medical facilities, the importance of frequent re-positioning of patients is something I will remember and implement
Taking care of the individuals that are getting older takes many different needs. Most of these needs cannot be given from the help of a family. This causes the need of having to put your love one into a home and causing for the worry of how they will be treated. It is important for the family and also the soon to be client to feel at home in their new environment. This has been an issue with the care being provided for each individual, which has lead to the need of making sure individuals have their own health care plan.
The transitioning nurse must be able to communicate clearly and effectively. Often times nurses working in the community are alone where there is no other health team member present, therefore complete communication is essential. Transitioning nursing must possess knowledge of computer technology. The use of computer technology allows the nurse to communicate with other healthcare providers, facilitate care and manage complex healthcare needs (Bates et al., 2016, p.342). Furthermore, nurses transitioning from an acute care setting must be able to adaptable to any given situation or community. For example, supplies and equipment found in a hospital setting can be different than the one found in a client’s home. They must take the opportunity to gather information on how to utilize the supplies or equipment that may be unfamiliar. Finally, transitioning nurses must be knowledgeable about community resources. Knowledge of community resources can provide the opportunity to access and share information and help to improve the client’s quality of life (Bates et al., 2016, p.
Most long-term care facilities have a nice, caring environment. Most facilities have exceptionally trained personnel caring for that family member’s needs and concerns. Being within the nursing field one notices the morale and the health of these forgotten individuals declining rapidly with no family bonds to connect to anymore. The nursing staff and facilities members, attempt to replace the bonds lost between resident and family. The bonds formed with staff and resident, are not equal to seeing a grandchild at holidays, and being included at that special family reunion. It is understandable some family units don t carry the tight connections other ily units share. Family support systems most require on admittance to semiprivate, busy nursing home settings are lost. Surroundings of this...