Transition Of Care Essay

Here are some numbers for tomorrow’s meeting. Between all of the providers from June 2016 until now, 51 percent are choosing MD Navigate to Coordinate of that 51 percent, 48 percent have MD Navigate in the To field. I have compared against referrals following the same workflow that have passed and the only difference that I have been able to extract is that on the ones that are failing, a Transition of Care does not look like it is being triggered. I have reached out to Patrick for an update over the course of this month, but to no avail. He stated he would be available next week and has access to email, so if I hear anything before next week I will keep you

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.

Extensive use of the word transition in nursing literature signals that it is a significant concept (Ralik, Visentin, Van Loon, 2006). It is essential for nurses to possess knowledge and understanding of transition. The purpose of this paper is to provide a comprehensive examination and explore the definitions and key elements of the concept of transition and show how gaining knowledge of transition can positively impact client care and the nursing profession. Understanding transition will help improve client care by teaching nurses how to assess for, and facilitate transition and develop health promotion initiatives. Ultimately, the goal is to have better outcomes for clients going through transition. Continued research and education

al, 2003). A systematic review of research consisting of effective discharge planning and how it affects hospital readmission rates was conducted. The review identified that effective discharge planning does have a direct correlation with the reduction of readmission rates. Patients that understand their diagnosis, medications and what to expect tend to have a better transition to home or nursing home. Also patients given support and information related to new medications and diagnosis are more successful at managing their health at home. Including the PCP is a great way to ensure the patient will have the necessary care and support to continue to succeed at home.

This 60 year old Hispanic male presents at the clinic today with a chief complaint of urinary frequency, decreased urine flow, increased nocturia, slight terminal dysuria and low grade fever. The patient was experiencing these symptoms for the past two years, but they had increased a whole lot more during the last two weeks. Upon assessment, it is noted that the patient has a

This intervention would be cost effective for the six hospitals involved. It is estimated that billions of dollars are spent yearly by Medicare on repeat hospital encounters(cite). The Center for Medicare and Medicaid (CMS) penalizes hospitals for readmissions within 30 days of the initial encounter. It is in the best interest of the hospital to implement programs and interventions that will help to mitigate the revolving door of repeat encounters. As a result of the potential loss in revenue from CMS the 6 hospitals are looking for interventions that will aid them in avoiding repeat encounter. This will ensure they will receive the

SC completed service coordination task associated with care plan rollover.SC rolled over PPL FMS ongoing monthly service fee, PAS service consumer option model Public Partnership (PPL), receives assistance w/ bathing, dressing, transfers and IADLs 7 days x 4 hours 7-9am and 4-6pm, provider PPL, PAS Taheerah, informal Shirley is informal back up. Pa confirms that she is receiving, type, scope, amount, duration and frequency through Self Directed consumer model. Per Pa, the aide continues to assist the Pa w/ his daily, bathing, grooming, IADLS excluding, money and telephone management. The Pa also, receives 7 frozen dinners weekly from Moms meal to supplement nutritious healthy meals, and Service Coordination via PCA. The Pa's has no informal

Stable, consistent health services greatly increase quality of care and positive treatment outcomes. [1] However, maintaining stable service, or continuity of care, increases in difficulty as the medical field grows more complex, especially for consumers who have received diagnoses that require the services of one or even several specialists. The concept appears simple. Nevertheless, continuity of care affects more stakeholders than one might imagine.

The transition to senior care marks a major change in life. Understandably, the move requires careful consideration, compassion, and respect. That’s why the caring staff at Keep ‘Em Home Personal Care Services in Lincoln, NE, keeps seniors’ best interests at heart with experienced and compassionate home care services.

I concur with your synopsis that the coordination of care across hospitals and care delivery networks-coordinating a multidisciplinary plan that moves clients across the continuum of care is the most essential function of the nurse case manager. Finally, case managers have the opportunity for greater responsibilities in care coordination from the acute, subacute arenas, home care to include long-term care as well (Dunham-Taylor & Pinczuk, 2015, p. 635)

The first key driver is that the process of discharge and clinical letters are not managed on time. In fact, the poor service performance was investigated and identified by the CCG in this GP surgery where the delay in discharge letters procedure has negatively affected on the result of service evaluation. Moreover, the delayed procedures of these letters will result in delayed transfer of care that can have catastrophic impact on patient’s life and increase the cost for both NHS and wider public sector. In terms of patient safety, the delay in follow up services can lead to worsening of their current condition or increase the chance of relapse on their previous condition and eventually rehospitalisation.

Excellent summarization of the Benner and Henderson theories, I agreed with Michelle, time won’t make the nurse transition from novice to expert. I have seen many nurses with five and ten years nursing but doesn’t make then expert, as a matter fact, I won’t allow them to take care of my family or me. In my opinion, what make a nurse expert is the wiliness of continuing education and don’t be afraid to ask questions. More questions you ask better nurse you will become. Stupid question is the one we don’t ask because we afraid to be judged and as a result we make mistakes.

Patient HH eligibility and/ or connection with care coordination (adding if phone call was made to CMA);

I have been taught that discharge starts on admission, and now I understand why that is. We as healthcare workers should not try to cram all of the information into the clients mind at one time. There is usually a lot of education that we need to do, and doing so only at discharge is not going to work. In my opinion, education was the biggest part of the discharge. From educating on medication, the importance of keeping and going to follow-up appointments, what to watch for and when to contact their provider if something does happen to them, and education on how to prevent further complications. Health promotion was also a big part of the discharge. Health promotion can decrease the change of a readmission, which is a plus for

Hospital readmission rates are one of the many metrics scrutinized by hospitals and payors alike (Boccuti & Casillas, 2016). When patients are discharged and readmitted within 30 days, this is a costly and concerning problem. Not only for the hospital but also for the patient (Jack et al., 2009). Studies have shown that when patients do not understand their discharge instructions, they have higher rates of 30-day readmissions (Regalbuto, Maurer, Chapel, Mendez, & Shaffer, 2014) and adverse events (Hastings, et al., 2011). The Johns Hopkins University’s Armstrong Institute for Patient Safety and Quality coined the term “Emergency department discharge failure” to describe events such as “ED return within 72 hours or more, poor compliance, or lack of comprehension”. They emphasized that these situations have significant clinical implications for patients, including unfinished treatments, illness progression and lower quality of life (2014).