Needs Assessment Plan For Action Case Study

Further research into my experience has revealed similar scenarios being played out across long-term care facilities nation wide (Kirsebom, Wadensten & Hedstrom, 2013). Premature discharging from hospitals has resulted in medication discrepancies, incomplete discharge orders, and inappropriate medical treatments. Recent studies show that three out four skilled nursing facility admissions experience medication discrepancies from the discharging institute (Tjia, Bonner, Briesacher, McGee, Terrill & Miller, 2009).

Patients recently discharged from acute care back to the community are at an increased risk for hospital re-admission (3). Efficient collaboration between interdisciplinary health professionals and nurse liaison can improve discharge planning processes.

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

Health care is something that everyone requires in order to lead a healthy life. After a visit to a hospital there are instances when certain individuals require further care due to their circumstances. Although hospitals may provide long-term care, it is not usually ideal. Hospitals are in place to handle emergency situations and aid in stabilizing the patients. Once the patients are stable, they must be transitioned to another facility if they require further assistance. This will avoid maximum occupancy for the hospital and allow it to remain available to other patients that may need their services. Patients who require long-term care or around the clock care and are in good medical condition should seek a long-term care facility, such as a skilled nursing facility or nursing home. For some individuals, facilities such as skilled nursing facilities or nursing homes are a blessing. These types of facilities are in existence to aid in the recovery of certain injuries and or to provide living arrangements for those who lack someone to care for them or assist with meeting their health care needs.

Skilled Nursing facility(SNFs) serve patients requiring preventive, therapeutic, and rehabilitative nursing care services for non-acute, long-term conditions. Specialized clinical and diagnostic services are obtained outside the nursing home. Most residents are frail and aged and often use canes, walkers, or wheelchairs. Nursing homes also care for a smaller percentage of restorative patients of all ages like a rehabilitation and other residents are in long-term recovery from acute illnesses, but no longer require hospitalization.

Deficiency of discharge planning can lead to lack of knowledge about diagnosis and confusion concerning medications. In a study researching patients being discharged from a teaching hospital in New York City, only 41.9% could tell researchers their diagnosis, 37.2% could remember the purpose of all their medications, and 27.9% could recite all their medications (Makaryus & Friedman, 2005). Insufficient

The office would need to establish a goal to accommodate all post-discharge patients. When appointments cannot be made then an escalation process to the office manager needs to occur. In order to foster communication with professional partners, an investigation of the system failures. How can the transition to home be improved? The workflow should include a validation step that would entail hand-off communication between hospital rounders and office schedulers. If missteps occur, then the office staff could catch the near misses and call the patient at home. Care coordination among providers on an outpatient basis could be supported by the electronic medical record and having verbal care conferences. Next strategy could involve the hospital completing a call back within twenty-four hours to all patients discharged. This intervention could potentially catch some of the missed opportunities. Another approach involves face to face reinforcement of the patient-centered partnership with H. H. According to Counsil et al. (2012), “patient-centered care plans for complex patients changed the relationships with the health team” (p. 190). The development of this patient directed plan of care and partnership is

Mr. Henry and his wife need medical care coordinated throughout the health care system to receive proper treatment and prevent health complications, encouraging their independence by remaining in the same setting. Marek and Rantz highlight that by providing care coordination and health care services for older adults residing in specially designed senior apartments, older adults will not have to move from one level of care delivery to another as their health care needs increase; and they will have the opportunity to “age in place” (Marek & Rantz, 2000). Care coordination starts with a comprehensive assessment of each of Henry and Ertha individual needs for health and social support, and by developing an individualized plan of care for each of them. “Patients should be evaluated, and care plans should be designed and implemented according to the individual needs of each patient (American Geriatrics Society, 2012, p. 1966). As Mr. Henry and his wife health care needs increase, they can receive periodical physical examinations to monitor their underlying health problems, and for early detection of complications remaining in their apartment. This will prevent negative outcomes associated with relocation, and medications and treatment noncompliance.

The main theme identified in this research focused on the Hospital readmission rate that has gained increasing attention because it reflects the effectiveness of healthcare system performance and the quality of patient care. The five articles studied all highlighted that an effective discharge planning is crucial to improve continuity of care between hospital and home/elderly home so as to improve patient’s health and reduce patient readmission. The themes that emerged described discharge planning in the hospital as pivotal in the continuing care of people who are in need of medical, social and rehabilitation care. Additionally as the needs of patients increase and become more complex, it is also important that an effective discharge planning system should have the capacity to discriminate and respond to different levels of need for coordination and post-discharge care (Central, 2012).

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?

A systematic review was conducted to compare patient outcomes after transitioning out of the hospital to another facility, home independently and home with support. Transitioning home with support was more beneficial than transitioning home independently and the reviews were mixed for home with support or transitioning to another facility (Boland, L., Briere, N., Emond, J., Garvelink, M., Guerard, Legare, F., G., McIsaac, D., Menear, M., Perez, M., Stacey, D., 2017).

Throughout Unit 6 we reviewed the continuum of care in long-term care facilities and its many aspects. The continuum of care, also referred to as the delivery system of health care, is best defined as a full range of long-term care services increasing in level of acuity and complexity from one end to the other (PowerPoint). This delivery system is comprised of three substantial components. These components are the informal system, community based care, and the institutional system.

The monitoring of critical factors affecting positive transition of health care will lead to a decrease in re-hospitalization of patients in this population.

Nursing home facility is for patients who need extended care because they are very sick or unable to function without continued nursing and supportive services in a formal health care facility. These patients are sick and/or are in need of assistance but they are not ill enough that they require the intense treatment and care offered at a hospital. About forty-seven percent of all nursing home facility care is paid for by Medicaid and residents and their families pay approximately one-third of the cost for the facility services. In recent years the length of time one stays at a nursing home has greatly decreased. Even with the decrease in stay there is still a fifty percent chance of an individual in his/her lifetime having to spend some time in a nursing facility. Both of these previous mentioned trends is reflective of the nursing facilities moving toward becoming more technologically sophisticated as well as being able to function as more of a

The article examined the issues that affect frail older adults who are being discharged from the hospital. When evaluating the research question it appears to be implied at the end of introduction. The author stated that the paper will indicate how healthcare team members (HCTMs) use the adult protective services (APS) system as a “safety net” when concerns are evident about an older adult’s decision concerning discharge from the hospital (Popejoy, 2008). To justify their research the author explicitly stated how healthcare workers are increasingly finding it a challenge to create discharge plans for older adults, which is due to a lack of services. Older adults make up the largest portion of patients,