Article summary Transitional care interventions refer to interventions that promote the safe and timely transfer of patients from hospital to home. The goal of transitional care interventions is to prevent repeated and avoidable readmission and negative health outcomes after a hospital discharge. The authors did a research study to examine the effectiveness of those interventions on reducing the readmission rates of patients with chronic illness in short (30days or less), intermediate (31 -180 days), and long terms (181-365 days). They selected 26 randomized controlled trials conducted in various countries during the period of January, 1980 – May, 2013. The article explained in great details of the selecting process of the 26 trails. It also …show more content…
explained the methods used for collecting, analyzing, and synthesizing data. After systematical review of the 26 trails, the authors found that transitional care interventions were associated with reduced hospital readmissions in intermediate and long terms. However, only high-intensity transitional care interventions were found effective in reducing short-term readmissions. The evidence suggests that to reduce short-term hospital readmission, transitional care should include high-intensity interventions, such as care coordination by a nurse, communication between the hospital and the primary provider, and a home visit within 3 days after discharge. Relevance to health system In our class, we talked about the fact that the current American healthcare system is disease centered and compartmented. We lack a coordinated healthcare system and patients receive services in bits and pieces. We believe that more resources and focus should shift to disease prevention and integration of different parts of the healthcare system to provide a continuous and holistic care. Transitional care interventions are one effort to provide holistic care for patient through coordination among different parts of the healthcare system. An effective transitional care intervention requires cooperation among hospital, primary provider, community and families. More importantly, transitional care can help to tackle the biggest challenge that American healthcare system faces - the high costs. The average costs per impatient day in the U. S. in 2013 are $1,878 for state/local government hospitals, $2,289 for nonprofit hospitals, and $1,791 for for-profit hospitals (Rappleye, 2015). This article also mentioned that nearly 1 in 5 patients who have been discharged from a hospital in the U.S. is readmitted to the hospital within 30 days, and up to 50% of these readmissions are preventable. The cost of unplanned readmissions has been estimated to be $12 - $44 billion annually. This article has proven that transitional care can effectively reduce the readmission rate to hospitals. Therefore, it significantly reduce the cost of healthcare. Besides, this article also mentioned that a stronger primary care structure could improve the performance of health system because research has shown that greater availability of community-based care is associated with reduced readmission rates. The importance of primary care in preventing disease and reducing healthcare costs is discussed extensively in this class. This article provides factual evidence to support this point. Reflection This article has changed my view on transitional care.
Now I believe that transitional care interventions are very important, yet undervalued in the healthcare system. There are not enough protocols in place to ensure the implementation and the quality of the transitional care interventions. As future nurses, I should advocate for the importance of the transitional care interventions and promote the utilization of those interventions. Besides, I feel that a significant cause of preventable readmission is poor communication and coordination of care during transitions. Transitions between care settings are vulnerable periods for all patients, but especially older adults and those with multiply comorbidities. We need to develop an effective system to identify the patients who are at high risk for readmission, and make plans accordingly to ensure optimal communication and coordination of services to provide continuity of safe, timely, high-quality care during transitions. In order to achieve this goal, we need to improve the quality of patient and family education, coordination and arrangement of care in the post-acute care setting, and the communication among healthcare professionals involved in the patient’s care
transitions.
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.
Although nurses do not wield the power of doctors in hospital settings, they are still able to effectively compensate for a doctor’s deficits in a variety of ways to assure patient recovery. Nurses meet a patient’s physical needs, which assures comfort and dignity Nurses explain and translate unfamiliar procedures and treatments to patients which makes the patient a partner in his own care and aids in patient compliance. Nurses communicate patient symptoms and concerns to physicians so treatment can be altered if necessary and most importantly, nurses provide emotional support to patients in distress.
A transitional care nurse or nurse navigator could be utilized to assure a smooth transition from the hospital into the community. The nurse navigator bridges the gap between the hospital care and post-acute care, while working closely with hospital staff, primary care doctors, specialists and community resources (Lamb, 2014, p. 191). Following the client’s discharge, a home health nurse would assume care and begin coordinating services. This nurse would be responsible to assure that all the care services are in place and there is a smooth
At the multidisciplinary meeting, the nurse will collect and assess the information provided by the other disciplines and family members stating that the patient is not at her prior level of functioning and then analyze the information to develop a diagnosis of deconditioning. Next, the nurse identifies outcomes for the patient to get stronger, achieve prior level of function, have activities of daily living (ADL’s) met in a safe environment by planning for home health, equipment, and 24/7 supervision through family or placement in a facility. This will be implemented by coordinating delivery of a walker and a 3 in 1 chair prior to discharge to daughter’s home with the home health agency nurse, physical therapist, and aide scheduled to start that day. In a week, the nurse evaluates that outcomes are being met by following up with patient, daughter, and home health agency evaluating that the patient is getting stronger, ADL’s are being met, and will soon be able to return to living independently. To achieve these standards of practice, every nurse should be aware of her own nurse practice act to ensure to be functioning with in the laws of the nurse’s state and to ensure the best outcomes and safety of the patients. In closing, it is every nurses duty to be the best nurse they are capable of being by looking at the scope of nursing practice which gives us the framework to achieve
Takeda, Taylor, Khan, Krum, & Underwood. (2012) states ‘(1) case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); (2) clinic interventions (follow up in a CHF clinic) and (3) multidisciplinary interventions (holistic approach bridging the gap between hospital admission and discharge home delivered by a team). The components, intensity and duration of the interventions varied, as did the ‘usual care’ comparator provided in different trials’. (P. 2).
Identifying the handoff practices currently in use will demonstrate the endeavor to examine options and recommend approaches for the future. Diverse forms of handoffs at different occasions for a large group of physicians, medical residents, nurses, allied health professionals and student clinicians from different disciplines have created inconsistencies. Besides, the bedside shift report has impacted patient and family satisfaction with the continuum of care. Examining a number of models, protocols, tools, standards and trends concerning patient-centered handoffs will highlight implications for the best practice. Recommendation for safer and more effective handoffs to improve practice and reach sustainable outcomes will be discussed to promote multidisciplinary approaches for patient-centered care. The transfer of critical information and accountability for patient care from one clinician to another is an essential component of communication in
Patients often have complex care needs, and often present with multiple co-morbidities or problems. The process of conducting a comprehensive nursing assessment, and the coordination of care based on these findings is central to the role of the Registered Nurse (NMBA 2006). Evidence-based interventions must then be planned and implemented in a patient-centred approach in order to achieve agreed treatment goals and optimise health (Brown & Edwards 2012).
Hospital readmission can impact the patient, nursing practice, the hospital, and the health care system. The patient’s quality of life can be altered physically, psychologically, and economically (Whittaker, 2014) and recurrent hospitalization is a good predictor of increased risk of mortality (Hummel, Katrapati, Gillespie, DeFranco, & Koellig, 2013). Moreover, a patient in an acute care setting has an increased risk of contracting hospital-acquired infections such urinary tract infections, sepsis, C. difficile, and methicillin resistant Staphylococcus aureus (medicare.gov|Hospital Compare, 2013). Nursing practice is impacted as patients spend the majority of their acute care stay with the bedside nursing staff. According to...
Canadian Journal of Cardiovascular Nursing, 23(3). Mesteig, M., Helbostad, J. L., Sletvold, O., Rsstad, T., & Saltvedt, I. (2010). The 'Standard' of the 'Standard'. Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study. BMC Health Services Research, 10(1), 1.
I attended a support group at 204 S Beverly Drive 116 Beverly Hills, CA 90212. The support group takes place every Tuesday from 6PM-8PM. If a team member cannot make it on Tuesday they can also attend on Saturday from 9AM-11AM. I attended a domestic violence class. The counselor name is Dr. Gordon, his License Marriage and Family Therapist. Dr. Gordon provides the following support group domestic abuse, domestic violence, emotional disturbance, Grief, Internet Addiction, and narcissistic personality and online anger courses and self-esteem. Once you enter the office there is coaches and it feels very comfortable. The instructor was sitting on his desk going over roll call and charging the fee. Once he finished roll call and charging he
In this event, the matter that is unusual can be the fact that I have experienced and witnessed the process for interprofessional collaboration between the community nurse and other professionals that I have never knew about before. This event made me realize that there are many aspects of community nursing that I have knew about before where in this situation it is the importance and accountability of interprofessional collaboration. From my nursing theory course I have learned that interprofessional collaboration is when the nurse forms relationships with other professionals that enable them to achieve a common goal to deliver care and strengthen the health system and clients involved in it. (Betker & Bewich, 2012, p.30) In this event, our mutual goal is to provide the appropriate care for the patients/residents so they can restore their health after their hip or knee surgery. In the nursing leadership and management textbook it stated “interprofessional practice removes the gatekeeper and allows client access to all caregivers based on expertise needed.” (Kelly & Crawford, 2013, p.35) In this event, my preceptor and I gained knowledge about Revera and will pass on this information to patients who are interested in staying at a retirement home after they discharge from the hospital. One literature talked about how according to the Institute of Medicine, it is critical to have the capacity to work together as part of the interdisciplinary team to assist in delivering high quality, patient-centered care. In addition, effective collaboration among health care professionals results in improved patient care and outcomes. (Wellmon, Gilin, Knauss & Linn, 2012) This indicates the importance of interprofessional collaboration to provide...
The first cause of poor transitional outcomes, cost, affects those who most commonly suffer from economic social determinants of health. Those with no insurance or with gaps in coverage are less likely to receive transitional care in comparison to those with adequate insurance due to inability to pay for necessary medical care (McManus et al., 2013). The issue is additionally compounded by the fact that up to 30% of CSHCN lack insurance coverage
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.
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.
This assignment intends to review the concept of nursing shift handover. Nursing handover can be defined as an important time to exchange information pertinent to the continued care of their patients (Pothier, Monteiro, Nooktlar et al. 2005). Methods of handover are varied, ranging from taped, verbal, by the bedside or with typed sheets.