NURS FPX 6610 Assessment 3 Transitional Care Plan NURS-FPX 6610 Introduction to Care Coordination

 

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Transitional Care Plan

Patient safety and quality of care are heavily reliant on transitional care, aiming to offer advanced facilities and services during the transfer of patients between treatment phases. Particularly crucial in chronic illnesses, continuous monitoring across treatment phases is imperative to prevent mortality, a task accomplished by a transitional care plan. This assessment explores the case of Mrs. Snyder, a 56-year-old patient with diabetes admitted to Villa Hospital for an infected toe. The focus is on discussing the transitional care plan for Mrs. Snyder and examining communication barriers that may impact the overall transitional plan (Korytkowski et al., 2022).

Key Elements & Information Needed for High-Quality Treatment

Patient care and safety improvements hinge on strict adherence to guidelines ensuring precision in diagnosis and effective tracking of patient medical records (Watts et al., 2020). Collecting Mrs. Snyder’s medical records is crucial for addressing her health issues comprehensively. These records not only aid in diagnosing specific health problems but also uncover other issues affecting overall health, such as depression, high blood pressure, and heart conditions (Chen et al., 2018).

In addition to medical records, understanding Mrs. Snyder’s medication list is vital for ensuring the appropriateness of her treatment. Medication reconciliation is necessary to determine the efficacy of her current medication and explore potential substitutes (Fernandes et al., 2020).

Obtaining information about emergency and advance directives is essential for providing patient-centered care. It helps in accommodating religious beliefs and understanding the patient’s treatment history from previous healthcare providers, minimizing potential conflicts (Dowling et al., 2020).

Patient feedback serves as a crucial element, offering insights into medical personnel behavior and the treatment process. Addressing patient concerns enhances the effectiveness of care and minimizes the risk of readmissions (Moghaddam et al., 2019).

Plan of Care and Education

Healthcare professionals play a pivotal role in tailoring care plans to meet individual patient requirements. This involves providing community-based healthcare services and facilitating rapid information exchange among healthcare professionals (Dyer, 2021).

Access to community and healthcare resources is vital for preventing adverse outcomes like hospital readmissions and mortality rates. These resources include mobility options, social support, health education, and outpatient treatment (Yue et al., 2019).

An insightful assessment of Mrs. Snyder’s needs requires comprehensive information such as medical test results, post-discharge prescriptions, time spent in the previous hospital, counseling documents, follow-up plans, social assistance and insurance coverage documents, current health condition, safety risk assessments, and detailed treatment and drug history related to chronic diseases (Humphries et al., 2020).