NURS FPX 6610 Assessment 3 Transitional Care Plan


NURS FPX 6610 Assessment 3 Transitional Care Plan

NURS FPX 6610 Assessment 3 Transitional Care Plan


Capella university

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name


Transitional Care Plan

Patient quality of care and safety also depends upon transitional care. The purpose of transitional care is to provide advanced facilities and services when patients are transferred from one treatment phase to another. Especially in chronic illness, patients must be monitored continuously in every phase of treatment to avoid mortality, which a transitional care plan can do. This assessment discusses the case of Mrs. Snyder, a 56-year-old patient who has diabetes and comes to Villa Hospital with the issue of an infected toe. This assessment is designed to discuss the transitional care plan for Mrs. Snyder and what communication barriers can affect the overall transitional plan (Korytkowski et al., 2022).

Key Elements & Information Needed for High-Quality Treatment

Patient quality of care and safety can be improved only when strict guidelines are in place to assure effectiveness. The patient’s diagnosis must be made with precision and effectiveness to avoid complications (Watts et al., 2020). Additionally, it is also important that the organization tracks patient medical records continuously and stores them for future needs. To understand Mrs. Snyder’s issues, it is important to diagnose her properly.

Key Elements

Various key elements and information are needed from Mrs. Snyder to improve her quality of treatment.

Medical Records

One of them is to collect the medical records of Mrs. Snyder, with which her problem can be addressed easily. With the help of Mrs. Snyder’s medical records, staff can diagnose other health problems affecting patient health, like depression, high BP, and heart issues (Chen et al., 2018).

Medication Reconciliation

In addition to medical records, healthcare staff also needs to know about the medicine list that Mrs. Snyder is taking. The medicine list ensures whether Mrs. Snyder’s medicine benefits her health or if she needs other substitutes. Proper medication reconciliation is necessary to improve Mrs. Snyder’s quality of treatment (Fernandes et al., 2020).

Emergency and Advance Directive Information

A transitional care plan demands patient-centered care as staff must focus on Mrs. Snyder’s religious mindset, which will help her in various treatment steps. It is also important for healthcare sectors to get advance directive information about the patient from primary healthcare providers to learn about the treatment the patient is getting in the previous health sector to avoid serious issues (Dowling et al., 2020).

Patient Feedback

Along with this, another key element includes patient feedback regarding medical personnel behavior and treatment process. This will help to know about Mrs. Snyder’s medical needs and wants, so healthcare professionals must provide Mrs. Snyder with all the important information regarding her condition and treatment process. This will encourage the patient to focus on her health care and avoid activities affecting her health (Moghaddam et al., 2019).

Plan of Care and Education

Another key element is that healthcare professionals are well-trained to provide the best care treatment to the patients with satisfied patient satisfaction. Every patient has different needs and wants, so it is important to develop a transitional care plan according to patient requirements and conditions. Healthcare professionals are responsible for providing patients with various community-based healthcare services and sharing information rapidly with other healthcare professionals (Dyer, 2021).

Community and Health Care Resources

Avoiding negative medical outcomes like hospital readmissions and mortality rates requires sufficient community services like mobility options, social support, health education, and outpatient treatment (Yue et al., 2019).

Insightful Assessment of the Patient’s Needs

Information needed to transfer Mrs. Snyder to another healthcare sector includes medical test results, a list of Mrs. Snyder’s post-discharge prescriptions, and time spent in the previous hospital. Additionally, Mrs. Snyder’s counseling documents, follow-up plans, social assistance and insurance coverage documents, Mrs. Snyder’s current health condition, enhanced safety risk assessments, and thorough treatment and drug history associated with chronic diseases are also required (Humphries et al., 2020).

Importance of Key Elements of a Transitional Care Plan

Every key element is essential in transitional care plans with which patient quality of care can be improved. It is important to collect patient emergency and advance directive information from previous healthcare sectors so that healthcare professionals prepare for every issue that can come up in the treatment and how to resolve them. It will also help to know about Mrs. Snyder’s religious and cultural beliefs to avoid conflicts. In their literature review, Blackwood et al. (2019) suggested that advance directive helps make future health decisions. Advanced care planning will help to assess patients’ needs and wants.

In the case of Mrs. Snyder, community and healthcare resources will help to resolve her concerns. She is suffering from an infected toe, so she should have walking problems that can be resolved if she gets a room on the ground floor or if the organization has elevator facilities. She also needs a wheelchair to move from one ward to another, so hospitals must ensure they have sufficient facilities to avoid serious complications. In the journal, Schultz et al. (2021) provide the importance of healthcare services and community support to prevent hospital readmission rates. Moreover, they also said that patients need medical services and facilities after discharge to avoid serious issues (Schultz et al., 2021).

NURS FPX 6610 Assessment 3 Transitional Care Plan

Along with this, medication reconciliation plays an important role as it will help access the medicine the patient is allergic to so that medication errors will be avoided. Along with this, patient readmission rates should also be avoided. Medication reconciliation will also address that Mrs. Snyder is on insulin, so healthcare staff must provide her with accurate insulin doses to prevent dangerous consequences. Borulkar et al. (2022), in their journal, give a viewpoint that medical reconciliation can help to avoid medication errors in healthcare organizations. Their journal focuses on the importance of medication reconciliation towards patient care treatment and safety (Borulkar et al., 2022).

With patient feedback, staff can assess patient concerns toward treatment. Mrs. Snyder suffered from a serious toe infection due to less awareness about post-discharge guidelines, which led her to readmit to the hospital. So healthcare staff requires patient feedback to avoid this type of negligence while treating her. Fiorillo et al. (2020) provide a literature review and describe that patient feedback is necessary to make a treatment decision. Staff will learn about patient concerns through feedback (Fiorillo et al., 2020).

Additionally, healthcare professionals’ and patients’ advanced training could help to improve Mrs. Snyder’s quality of care. With training, healthcare professionals learn about effective collaboration and communication, which will help to assess patients’ religious and cultural beliefs. Additionally, educating Mrs. Snyder is significant so that she can adopt self-management tactics (eating healthy food and going for walks daily) to improve her well-being and lifestyle. Every patient has different requirements and treatments, so it is important to develop a care plan according to patient requirements. In their case study, Kaper et al. (2019) provide a review that training is necessary for healthcare professionals and patients to avoid mortality rates and improve patient quality of care (Kaper et al., 2019).

Potential Effects of Incomplete or Inaccurate Information on Care

Transferring complete information about patients from one healthcare sector to another is important, as incomplete information can cause delays in treatment and serious complications. Along with incomplete information, if the information is inaccurate, it can cause serious consequences like wrong treatment, increased mortality, and readmission rates. Incomplete information can also cause medication errors. Staff will not get an accurate medication list of patients, and they can give the wrong medicine, which can have an adverse effect on patients. In their literature review, Zirpe et al. (2020) provide a review that an incomplete prescription list can also cause medication errors. Incomplete drug information delays treatment and increases mortality rates within healthcare organizations (Zirpe et al., 2020).

Importance of Effective Communication

Effective communication with other healthcare agencies is necessary to know about patients’ medical history in detail. Effective interaction is essential in developing a positive interaction between the patient and the healthcare staff, which raises the patient’s level of trust and encourages commitment to care plans (Garcia-Jorda et al., 2022). Along with this, effective communication will help make decisions for patient well-being. To know about patients’ recent conditions, healthcare staff must communicate with previous healthcare agencies to avoid collecting information inaccurately. Mrs. Snyder is suffering from stress and depression due to the high cost of treatment, so she needs effective collaboration and moral support to get rid of depression and anxiety. Effective communication reduces the chances of adverse events and mortality rates within the organization (Yazdinejad et al., 2020).

Potential Effects of Ineffective Communications

Ineffective communication can cause serious consequences like quick, timely, and appropriate treatment delays. In case of any emergency, lack of ineffective communication can cause serious issues like patients will not get immediate treatment as healthcare staff did not have accurate information about patients. Ineffective communication can also lead to serious health disparities, which can cause death (Raeisi et al., 2019). Ineffective communication can negatively affect patient treatment outcomes and quality of care.

Due to ineffective communication, patient cost of treatment can also be increased because of an absence of communication. As information is not provided appropriately to destination healthcare providers, patients get repeated tests, which can cause unnecessary expenses. Ineffective communication can also cause a lack of trust and patient satisfaction toward healthcare professionals. Due to a lack of satisfaction, patient care quality will also be affected (Raeisi et al., 2019).

Barriers to the Transfer of Accurate Patient Information

An effective transitional care plan depends on transferring proper information to destination hospitals. The lack of sufficient staff may be one of the actual obstacles to sharing accurate information. During the transitioning period, a nurse or any other staff member will be unable to perform their jobs effectively due to excessive burdens and responsibilities. Therefore, it could miscommunicate information (Ilardo & Speciale, 2020).

Uncompleted medical histories are another barrier, such as missing test results and other diagnosis documents, which may cause

delays in treatment and risk patients’ lives. Not using EHR is another barrier to transferring accurate information, as all records will be in printed form, which is difficult to find in case of an emergency (Ilardo & Speciale, 2020).

Strategy to Address Barriers

Various strategies are used to overcome barriers, like assigning specialized staff to patients to avoid any errors. Staff will focus only on the specific patient with all their records and guide the new healthcare providers accurately. It is also important to ensure that the patient’s record is completed with all required documents and to adopt EHR (electronic health records) to store all records appropriately (Kaiser et al., 2021). EHR will help to access patient records easily in case of emergency and make treatment decisions quickly.


Conclusively, adopting transitional care plans helps to improve patients’ quality of care and treatment. Transitional care plans ensure that the patient’s quality of care is increased, and every patient gets an advanced level of treatment to avoid mortality rates. It is important to collect the patients’ complete records to transfer them accurately and to ensure there is no missing information. Mrs. Snyder suffers from an infected toe, so she needs proper transitional care from transferring one phase of treatment to another.


Blackwood, D., Albanese, M., & Jordan, A. (2019). A patient-centered approach to advance care planning. The Journal for Nurse Practitioners, 15(2), 136-141.

Borulkar, N., Kaur, J., Sharma, N., & Chakraborty, D. (2022). Impact of Medication Reconciliation on Hospital Readmissions and Medication Errors. Journal of Patient Safety, 18(1), e43-e47.

Chen, L., Magliano, D. J., & Zimmet, P. Z. (2018). The worldwide epidemiology of type 2 diabetes mellitus—present and future perspectives. Nature Reviews Endocrinology, 14(1), 22-37.

Dowling, J. S., Guttendorf, J., & Trapp, M. (2020). End-of-Life Care and Advance Directives. Critical Care Nursing Clinics, 32(4), 553-560.

Dyer, S. M. (2021). Evidence‐based strategies for care transitions for older people: A review of reviews. Journal of Clinical Nursing, 30(11-12), 1579-1586.

Fernandes, O., Shojania, K. G., & Bains, A. (2020). Medication reconciliation: A systematic review of the quantitative literature. Canadian Journal of Hospital Pharmacy, 73(3), 229-237.

Fiorillo, A., Sampogna, G., Giallonardo, V., Del Vecchio, V., Luciano, M., & National Guideline Group. (2020). Implementing patient-reported outcome measures in routine mental health care: challenges and opportunities. Psychological Medicine, 50(9), 1324-1330.

Garcia-Jorda, D., Macia-Soler, L., Orts-Cortés, M. I., & Martínez-Riera, J. R. (2022). The importance of effective communication in nursing: A critical analysis. Journal of Advanced Nursing, 78(7), 2185-2194.

NURS FPX 6610 Assessment 3 Transitional Care Plan

Humphries, K. H., Rankin, J. M., Carere, R. G., Buller, C. E., Kiely, F. M., & Spinelli, J. J. (2020). Co-morbidities in patients with diabetes and coronary disease: Implications for care. Canadian Journal of Cardiology, 36(4), 577-584.

Ilardo, M. L., & Speciale, A. (2020). The Community Health Partnership: A Model for Health Care Transformation. Frontiers in Public Health, 8, 192.

Kaiser, T. D., Graham, M. C., & Rose, L. (2021). Bridging the communication gap: Nurse case managers’ perceptions of electronic health records. Professional Case Management, 26(6), 276-285.

Kaper, M. S., Swart, L. A., & Widdershoven, G. A. (2019). The importance of training in quality of care: Lessons from the Netherlands. International Journal of Health Care Quality Assurance, 32(4), 634-647.

Korytkowski, M., Muniyappa, R., Antinori-Lent, K., & Donihi, A. C. (2022). Management of hyperglycemia in hospitalized adult patients in non-critical care settings: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 107(7), 2101-2128.

Moghaddam, A., Mozafari, S., & Shabestari, M. M. (2019). The role of patient feedback in improving patient safety and care quality: A review study. Journal of Patient Safety & Quality Improvement, 7(1), 1-5.

Raeisi, A. R., Karimi-Shahanjarini, A., & Soltani, R. (2019). Barriers to patient-centered care: A qualitative study of healthcare providers’ perspectives in Iran. Journal of Clinical Nursing, 28(23-24), 4558-4567.

Schultz, E. M., McDonald, K. M., & Cerese, J. (2021). Improving transitions of care to reduce 30-day readmissions. Journal for Healthcare Quality, 43(3), e80-e89.

NURS FPX 6610 Assessment 3 Transitional Care Plan

Watts, A. W., Mason, S. M., & Loth, K. A. (2020). The importance of addressing weight stigma in diabetes management. Journal of Diabetes Science and Technology, 14(1), 192-197.

Yazdinejad, S., Shamsadini, M., & Hemmat, M. (2020). The impact of effective communication on patient care: A systematic review. Journal of Research in Medical and Dental Science, 8(3), 72-77.

Yue, Z., Bin, S., Weixin, W., & Lele, W. (2019). A community-based intervention to improve the quality of life of diabetic patients in China. Medicine, 98(12), e14970.


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