What Are The Challenges Of Care Transitions

This week I have fully grasp the work that goes into being an RN, case manager and what it entails to fully review a patients’ stay at the hospital in order to discharge them in the most effective and efficient way. I understand the need for these professionals in the healthcare field, not only in the hospital setting, but in skilled nursing facilities as well, one reason being is that I believe someone has to advocate and review the patients’ needs before they are sent home. Just like last week I was able to sit in on rounds and observe a great deal of the doctor and case manager dynamic and how important it is for both to know the patient as much possible. Sitting in rounds every morning makes me realize how hard it is to make decisions for another

My second clinical day took place on September 24th, 2015 at Saint Barnabas Hospital in Livingston, New Jersey. My preceptor Maria Brilhante, MSN, RN, allowed me to observe the morning huddle that took place with all the nurse managers that are in the hospital. The purpose of this huddle was to keep the director of nursing informed about the census on each unit. I found this processed to be very uniformed and professional because the DON was engaged. The day went on with me attending meetings on how managers could implement plans to contain cost for the hospital. Maria did her daily rounds on her patients and her nursing staff. She has a folder that contains papers on how each nurse is progressing from the time they get off orientation. Her motto to the nurses is, “You are good at what you do, so when I coach don’t take offense. I am only trying to get you to be great”. This boost their confidence which I thought to be important.

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,

L.P., a currently practicing NP, was interviewed in an attempt to explore her thoughts on issue and possible solutions affecting NPs. L.P. started her education with a bachelor’s degree in education. She later returned to school to receive her registered nurse (RN) license and gained experience working in several hospital departments for over 20 years. During this time she worked on completing a master’s in healthcare administration and wellness promotion. She later returned to Drexel to complete her bachelor’s and master’s in nursing to work as a Family Practice NP. She has been practicing as an NP for five years, with her start in a physician practice and is currently working in the

Globally, unlike in the past, it is rare for a patient to consult with the same healthcare provider over their lifetime, often referred to as healthcare provision “from the cradle to the grave” of a patient (Mostert-Phipps, Pottas & Korpela, 2012). This rarity is credit to the fact that currently patients move between healthcare providers due to various reasons (Medical School, 2003; Naylor & Keating, 2008; National Transitions of Care Coalition, 2010; Picton & Wright, 2012; Masango-Makgobela, Govender & Ndimande, 2013). The Joint Commission (2013) terms this movement as the “transition of care”. However, this transition of care results in the fragmentation of provision of patient healthcare, and thus challenges continuity of care (CoC) (Haggerty

There are many different professions that one can choose when entering the healthcare field. Nursing is a very popular and needed profession that is vital to care for patients. For this paper I have chosen to interview my younger cousin who currently works for the VA Hospital in Las Vegas, Nevada as a Registered Nurse in the Medical Surgical Unit. I will describe the targeted facility and unit she works for, the type of work done within her unit, any interesting, informative, or specific information related to the chosen unit which makes it unique, and a comprehensive description of my cousin, and her responsibilities.

For my interview, I spoke with one of the Nurse Practitioners (NP) that I interact with while working my shift at the hospital. I will call her Terri Smith because although I asked to use her quotes in my paper, I did not think to ask for permission to use her actual name. Where I work, many of our internal medicine physicians are hospitalists. During the night, they are covered by the umbrella of Quest Care. There are several NPs that work under the afore mentioned physicians and are there, on-call, when needed for their clinical expertise. It is nice, because even though I can’t develop much of a relationship with the doctors whose patients I work so hard to take care of, I get to have the opportunity to grow strong bonds with the NPs that I see almost every shift.

Nursing can be a demanding career, but the benefits far much outweigh the challenges. Most importantly, it’s the rewards it offers by allowing an opportunity to make a difference in another person’s life through the provision of care when they need it. Just as Patricia Benner theorized in her book “Novice to Expert,” nursing encompasses both educational knowledge and extensive clinical experience acquired throughout one’s career. This far, I continue to acquire knowledge and clinical knowhow which will promote proper and efficient care to patients. Since I began practicing one year ago in a long-term healthcare facility, I have interacted with patients, families, physicians and other members of the healthcare team to coordinate patient’s care which has enabled me to gain confidence in myself. While I cannot deny that it was difficult to transition from a student to a licensed nurse, I learnt to overcome these challenges and focus on my strengths. Practicing as an LPN has provided a platform to learn and gain experience even though the duties and responsibilities are limited by the scope of practice.

As a practitioner or a population health coach, both APNs considered other nurses at any level, and physicians within the same discipline, as her peers. Over the course of their professional careers, increased confidence, trust, and knowledge were the commonalities with evolving roles. The confidence and trust originates with oneself, then, includes that of her co-workers and physicians, but mostly from her patients. Maturing from the novice RN to an expert APN, the confidence and knowledge base has developed, building an individual practice and supporting patients and communities towards optimal health. Each considered autonomy the greatest privilege guaranteed them as APN.

First of all, I recognized that I was dealing with humans, and not just dealing with a disease process and application of the nursing process in the aspect of restoring patient health. I was dealing with emotions, and families, and cultural beliefs that influenced individual’s aspects of care. I started to see that health did not just incorporate healing the disease, but also recognized the importance of making sure patient’s felt that their

This DM experience I felt was challenging in that my client is an older adult whom has always made her own decisions about how she lives her life (which was impacting her life) and developing specific goals, objectives and initiatives that focus on making change. It felt is would be challenging around her lifestyle habits to make change. My plan for this was to develop a nurse client relationship where p felt comfortable and allowed me to share information about ways in which we could improve her health. I felt the first step was ensure I involved I shared with her information to diagnosis, contributing factors to her illness and supportive initiatives in which she could move forward to develop change thought educated decision making.

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

During my first semester student clinical rotation, I was introduced to patient, 76 year old AB who was being treated at an assisted living facility. She was a wonderful patient and someone I immediately connected with. AB had been medically diagnosed with COPD and displayed all the classic physical signs of the disease such as wheezing, deliberate breathing, severe shortness of breath and nutritional deficit. She was my first patient as a student nurse and the first person I was able to complete a health assessment and nursing care plan for. I recognized early on that AB was special and someone who would be a great person to communicate with. With the initial assessment she was a little scared, but

Several of the roles which I observed this morning were expected: the nurses took vitals for incoming patients, performed focused assessments, and were the main communicators between family, the patient, and the physician. I realized when the first patient came in around 10:00 am, the RN’s role in assessments, gathering blood work, and carrying out all the necessary steps to situate and stabilize the patient as soon as possible. It was incredible seeing the nurses work together, in sync, in those first moments when the patient was brought in. And though expected, I appreciated seeing just how much communication was held and information was gathered from the patient or family members by the nurse. Jessica asked the right questions from both parties, while still showing incredible empathy and not making the whole situation seem rushed and flustering. I understood this as another essential role of the nurse in the ED; he or she must maintain even in such a fast-paced environment empathy and focus in each interaction.

I would like to discuss my communication experience with patient that happened in nursing home during placement. To describe the situation, I will use Gibbs’ (1988) Model of Reflection. Pete Lindsay, Jeff D. Breckon, Owen Thomas, & Ian W. Maynard, 2007, pg. 340 explained this model as a cyclic approach which facilitates the continual development of practitioners as they progress through each six stage involved in it. It was my first placement and I was gleeful. I was given an opportunity to work independently on the third day. To begin with, I will describe about the condition of my patient, my feelings when I met him, good things which I learnt, impact of this communication on our relationship, discovered innate trait of myself and the areas in which I thought I need to improve.