National Transition Of Care: A Case Study

Everyday nurses are learning something new. There is constant change as nurses face new challenges and advance their career. There are two models of transition that consider these challenges associated with change (Blais & Hayes, 2016). Bridges model of transition consists of three phases and he believes we go through all three as we experience change (Blais & Hayes, 2016). The first stage is the ending phase, which involves letting go of the past and discontinuing a connection (Blais & Hayes, 2016). When I got accepted into the nursing school I transitioned from a regular college student to a nursing student, which meant strictly focusing on passing nursing school. Once I pass the national state exam, I transition to a Registered Nurse. Then I transitioned from my employment setting as a waitress to a medical surgical telemetry nurse in a hospital setting. Within the ending phase, Bridges also describes four components: the second phase is the ending phase. It has four sections: disengagement, disidentification, disenchantment, disorientation. I fall under disenchantment, I currently work night shift and I have never been a night person. When I first started working night shift I was disoriented to time and constantly felt tired when I was out of work. I have now adapted to the schedule and can balance working nights and not being tired during the days when I am off. The second stage is the neutral zone, which consist of accepting your new role, however, the

The purpose of this paper is to bring forth awareness when it comes to patients and medication errors and further educates health care professionals on the importance of communication especially during transition of care. According to Williams and Ashrcoft (2013) “ An estimated median of 19.1 % of total opportunities for error in hospitals.” Although not all medication errors occur during transition it is the time most prevalent for these errors to occur. As per Johnson, Guirguis, and Grace (2015) “An estimated 60% of all medication errors occur during transition of care. The National Transitions of Care Coalition defines a transition of care as the movement of patients between healthcare locations, providers, or different levels of care within the same location as their conditions and care needs change, [and] frequently involves multiple persons, including the patient, the family member or other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s), physician(s), and other providers.”

Requirements: a multidimensional transformation of primary care practice with intensive case management and a payer partnership.

Decrease in funding is another economic challenge in health care. The amount of finances coming from various sources not just the

In my workplace things change on daily basis, problems occur. That means that systems in place might need changing. It is mine responsibility that policies, procedures and systems of communicating are kept up to date and those in place are correct. Care Plans, documents are checked on regular basis, reviewed and up dated when required. Residents’ needs change from day to day therefore we have formal or informal chats to discuss what has changed and how to meet these needs. Handovers also keep staff informed about new happenings. Policies that are changed through companies are out into practise and old files archived. Information that is no longer in use is stored away and archived. We have in place procedures that we follow and hand them over

Transition of care appeals to me the most in my practice as a case manager. When a patient gets admitted, the interdisciplinary team starts working on the discharge planning. I always wonder how can the team know for sure, that the patient is ready to be transitioned and how can we know for sure that the transition of care is safe and it would not be overlook?

As evidenced by the constant battle over health care reform, healthcare in the United States has become a growing problem that must be addressed. While the main controversy seems to be the politics of healthcare reform and whether the government should have total control, the one thing that I believe should be the focus, is the quality of care that is embedded in the patient doctor relationship. It’s quite troublesome when large health insurance companies are swaying politicians to vote for less health care regulation and higher premiums rather than focusing on the quality of care and the importance of the patient doctor relationship, which has become overshadowed. That is why I believe it is important to look at and consider how health care reform such as the PPACA and policies implemented by private insurance companies have affected the doctor-patient relationship and thereby influenced the quality of medical care. One of the many reasons that I find this an interesting and important topic is because I aspire to work in the medical field and the interaction between patients and doctors is important for me to consider and determine how it has changed, whether it be for better or worse, throughout the years as a result of added regulations and new reforms.

About 57,436 Veterans chose to use Non-VA (Department of Veterans Affairs) facilities for healthcare service while waiting more than 90 days for appointments with their VA clinicians (Couzner, Ratcliffe, & Crotty 2012). Since post-hospitalization follow-up with primary care providers has a great impact on theses Veterans’ health outcome by promoting recovery and preventing readmissions (Martinez, 2014). The Patient Aligned Care Teams track Veterans’ admission and discharge in VA facilities through the VA’s electronic medical record to ensure timely post-hospitalization with Veterans’ primary care providers. There are no data about post-hospitalization follow up among Veterans who is admitted into Non-VA facilities.

Recognizing this growing problem, some physicians around the country have decided to tackle this issue. This paper will explore the problem of people being unable to access continuous healthcare as well as some reasons why this occurs. It will also reveal a new initiative called the Student Ho Spotters Program that has been created and tested out at hospitals around the country that aims to get people the established care that they need.

The transitioning to a long-term care facility can be scary and stressful for residents, and some may find it difficult to adjust. I agree with you that the enabler role can be of great assistance to the resident and their families to help reduce the stress of entering a new facility. The frequent visits and encouragement from the social worker will let both the patient and their family know they will not be alone during this transition. Have you ever had to utilize the services of a social worker? In my current position, I come into contact with patients who require the support of a social worker typically for help with resources that they need to attain. Being a social worker is a demanding position since they are there to assist the patient,

Even though change looks dim, there have been many strategies to make it an easier transition. America must continue its progress towards universal healthcare with small steps. The government leaders must also recognize their duty as leaders to stand as a representative of the people. They must also recognize their moral and ethical position. This will help the citizens to have a chance to fight for their beliefs. These men and women who are defending the people should understand their audience as well (Vladeck). They should also fight for the education of the citizens so that healthcare wouldn’t be as big of an issue. This would provide an easier process towards universal healthcare if people understood how to be healthy (Szasz). Lastly, political leaders need to understand that the steps that they need to take should not be incremental because those types of steps/progress have not been sufficient enough to decrease the amount of uninsured people (Vladeck).

As financial manager, my role is a complex one covering many different areas of my clients finances. My role requires me to have a full understanding of the finances and how my company is ran. I am responsible for managing the budget and allocating funds amongst the different departments in relevance to importance, in order to keep the company running successfully. Choosing to invest in a company is a huge decision , requiring a rigorous amount of research. This research is done in order to determine whether the companies are a good fit for each other. The amount of research conducted can make the difference between my investor increasing their profit and losing money.

The biggest take-away I have from watching the Improving Transitions of Care videos is that transition of care has been and continues to be a huge ongoing problem with poor communication between the healthcare providers and the patient. As posited by Dr. Eric Coleman in the Module 1 video, we should consider one in five Medicare patients being readmitted within 30 days of discharge from the hospital as unacceptable (Joint Commission Resources [JCR], 2010). According to the video series, there are several projects being implemented to improve the discharge planning process and thus decrease the need for hospital readmission (JCR, 2010). A few of the tools being used such as, the After-Hospital Care Plan, more comprehensive teaching about diagnosis,

Dr. Robert Master, the founder of Commonwealth Care Alliance (CAA), had created the company with the vision to ‘bring high-quality and personalized care to people with complex medical and behavioral needs, resulting in improved health and better self-management of chronic illness, thereby reducing hospitalizations and institutionalizations.' Therefore, the main objective was to provide care outside the walls of hospitals and institutions to make it easier for the chronically ill and disabled to receive the attention they

The healthcare system has seen significant change over the past decade. This is due to improved technology, healthcare reform, and the economic crisis (Hendren, 2010). With the changes that are occurring,