NURS FPX 6201 Assessment 4 Transitional Care Interventions

Name

Capella University

NURS-FPX6201

Instructor’s Name

October, 2024

Table of Contents

Transitional Care Interventions

Preventive care includes transitional care to address gaps in the management of care patients as they are transferred from one setting to another (Cuzco et al., 2021). Transitional care interventions have to be carried out effectively and help to reduce hospital readmissions because patients’ care needs are not met adequately as they transition to their homes (Haris et al., 2022). This summary reviews several interventions undertaken for transitioning patients from hospital to home and examines other programs aimed at enhancing posthospitalization patient outcomes, with input on the value of continuity, medication administration, and patient counseling.

Annotated Bibliography

Cuzco, C., Torres-Castro, R., Torralba, Y., Manzanares, I., Muñoz-Rey, P., Romero-García, M., Martínez-Momblan, M. A., Martínez-Estalella, G., Delgado-Hito, P., & Castro, P. (2021). A systematic review of nursing interventions for patient empowerment during intensive care unit discharge. International Journal of Environmental Research and Public Health, 18(21), 11049. https://doi.org/10.3390/ijerph182111049

Cuzco and others describe a transitional care model that is patient-centered with major concern for those with high risk, particularly the chronically ill. Their strategy incorporates both operational communication between healthcare professionals as well as discharge planning. The care management model identifies a care manager for the patient and coordinates his/her care before and after discharge through medication reconciliation and follow-up evaluation. The study reveals that the patients who attended the program diminished the 30-day readmission rates by 20% than the other patients. Although a brief transitional care plan was tested in the study, the important concepts of follow-up care and proactive communication to guide post-discharge management are both identified.

Harris, M., Moore, V., Barnes, M., Persha, H., Reed, J., & Zillich, A. (2022). Effect of pharmacy-led interventions during care transitions on hospital readmission: A systematic review. Journal of the American Pharmacists Association: JAPhA, 62(5), 1477–1498.e8. https://doi.org/10.1016/j.japh.2022.05.017

Haris and colleagues surveyed a systematic review of pharmacist-led interventions that decreased hospital readmission rates. Their review involved 15 papers in various inpatient hospital settings and according to the findings, pharmacist-contributed care cut the readmission rate considerably. During medication reconciliation and counseling at discharge, pharmacists make patients understand the prescriptions and effects, the side effects included, and why they must adhere to medications. The authors of the review estimate that pharmacist-led interventions enhance patient knowledge of their clinical management plan, diminishing the risk of manifestations of medication-related issues that may lead to the patient’s readmission to the hospital.

Tate, K., Cummings, G., Jacobsen, F., Halas, G., Van den Bergh, G., Devkota, R., Shrestha, S., & Doupe, M. (2024). Strategies to improve emergency transitions from long-term care facilities: A scoping review. The Gerontologist, 64(7), gnae036. https://doi.org/10.1093/geront/gnae036

To this end, the study of Martin et al. focuses on the role of home health visits in decreasing emergent department visits and readmissions of older patients. This intervention refers to the home visits of HC professionals shortly after discharge to assist patients with medication administration, exercise, and general observation. Research evidence reveals that access to PC-SPIN reduces the utilization of the emergency department and readmission within the first 60 days of discharge. The study underscores home health visits whereby the patient receives vital care from a home health aide to attend promptly to their healthcare needs in order not to exacerbate pre-existing illnesses that would compromise their health status due to old age.

Verhaegh, K. J., MacNeil-Vroomen, J. L., Eslami, S., Geerlings, S. E., de Rooij, S. E., & Buurman, B. M. (2014). Transitional care interventions prevent hospital readmissions for adults with chronic illnesses. Health Affairs (Project Hope), 33(9), 1531–1539. https://doi.org/10.1377/hlthaff.2014.0160

The characteristics of telehealth-based transitional care are described by Verhaegh and colleagues for older patients post-discharge. Thus, the program is based on the use of e-visits together with remote health monitoring tools for patients with impaired mobility. This trail confirms that the use of telehealth interventions can significantly cut readmissions by 15% by allowing patients to seek medical advice/monitoring at appropriate times. The researchers also identify aspects such as convenience and patient engagement which may result from telehealth in enhancing satisfaction with service delivery since patients may not be required to attend many hospital visits. The study suggests that similar telehealth transitional care programs should be established to support elderly patients with social and transport problems.

Wei, S., McConnell, E. S., Granger, B., & Corazzini, K. N. (2022). Care coordination processes in transitional care for patients with heart failure: An integrative review through a social network lens. The Journal of Cardiovascular Nursing, 37(6), 546–557. https://doi.org/10.1097/JCN.0000000000000872

This paper assesses the impact of nurse-led transitional care coordination for multiple asossiated patients. The intervention includes the hiring of a specialized nursing staff that is assigned to work only with patients in the study starting from admission up to follow-ups after they leave the hospital regarding medication adherence and symptoms. These findings provide evidence that patients managed by nursing-led transitional support scored higher on health status and had a lower readmission rate compared to patients who did not receive such help. These favorable effects the researchers have related to patient education, identification and prevention of early signs of complications, as well as follow-up evaluations. Based on the study, this model is recommended for implementation for other higher-risk patient groups because of improved patient satisfaction and healthcare costs.

NURS FPX 6201 Assessment 4 Conclusion

The papers reviewed in the course of the present work provide evidence of the utility of targeted, individualized transitional care services, including discharge planning, medication reconciliation and optimization, nursing-led coordination and follow-up, home visits, and telemedical support. All of them strengthen patient needs, and continuity of care throughout the patient’s medical day, and assist in averting adverse conditions that may result in readmission (Pedrosa et al., 2022). Taken together, these works call for increased application of these strategies in diversified contexts of health care to address the multifaceted needs of targeting, high liability patients, especially the elderly and chronic-illness patients. The enlargement of such programs will not only improve the quality of patient care, but it will also improve healthcare organization, productivity, and cost-effectiveness as well.

NURS FPX 6201 Assessment 4 References

Pedrosa, A. R. C., Ferreira, Ó. R., & Baixinho, C. R. S. L. (2022). Transitional rehabilitation care and patient care continuity as an advanced nursing practice, 75(5), e20210399. https://doi.org/10.1590/0034-7167-2021-0399

Saragih, I. D., Everard, G., Saragih, I. S., & Lee, B. O. (2024). The beneficial effects of transitional care for patients with stroke: A meta-analysis. Journal of Advanced Nursing, 80(2), 789–806. https://doi.org/10.1111/jan.15850

Tate, K., Cummings, G., Jacobsen, F., Halas, G., Van den Bergh, G., Devkota, R., Shrestha, S., & Doupe, M. (2024). Strategies to improve emergency transitions from long-term care facilities: a scoping review. The Gerontologist, 64(7), gnae036. https://doi.org/10.1093/geront/gnae036

Wei, S., McConnell, E. S., Granger, B., & Corazzini, K. N. (2022). Care coordination processes in transitional care for patients with heart failure: an integrative review through a social network lens. The Journal of Cardiovascular Nursing, 37(6), 546–557. https://doi.org/10.1097/JCN.0000000000000872