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NURS FPX 6610 Assessment 3 Transitional Care Plan

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    NURS FPX 6610 Assessment 3 Transitional Care Plan

    Student Name

    Capella University

    NURS-FPX 6610 Introduction to Care Coordination

    Prof. Name


    Transitional Care Plan

    Patient safety and quality of care are closely tied to transitional care. The objective of transitional care is to offer advanced facilities and services during the transfer of patients from one treatment phase to another. This is particularly crucial in chronic illnesses, where continuous monitoring across treatment phases is essential to prevent mortality, a task effectively managed by a transitional care plan. This assessment delves into the case of Mrs. Snyder, a 56-year-old patient with diabetes admitted to Villa Hospital due to an infected toe. The focus is on discussing the transitional care plan for Mrs. Snyder and examining communication barriers that may impact the overall transitional plan (Korytkowski et al., 2022).

    Key Elements & Information Required for High-Quality Treatment

    Patient care quality and safety hinge on stringent guidelines to ensure effectiveness. Precise and effective diagnosis is fundamental to prevent complications (Watts et al., 2020). Continuous tracking and storage of patient medical records are imperative for future reference. In Mrs. Snyder’s case, a thorough understanding of her medical condition is vital for proper diagnosis.

    Key Elements

    Several key elements and information are required from Mrs. Snyder to enhance the quality of her treatment.

    1. Medical Records: Gathering Mrs. Snyder’s medical records is essential to address her health issues comprehensively. These records aid in diagnosing other health problems such as depression, high blood pressure, and heart issues (Chen et al., 2018).
    2. Medication Reconciliation: Knowledge of the medications Mrs. Snyder is taking is crucial. Medication reconciliation ensures that her prescribed medications are beneficial, avoiding errors and improving the quality of treatment (Fernandes et al., 2020).
    3. Emergency and Advance Directive Information: A patient-centered approach is necessary for a transitional care plan. Understanding Mrs. Snyder’s religious beliefs is essential. Obtaining advance directive information from primary healthcare providers helps in understanding the patient’s previous treatment and prevents potential issues (Dowling et al., 2020).
    4. Patient Feedback: Gathering feedback on medical personnel behavior and the treatment process is crucial. This information aids in understanding Mrs. Snyder’s needs and preferences, ensuring that she is well-informed about her condition and treatment (Moghaddam et al., 2019).
    5. Plan of Care and Education: Healthcare professionals should be well-trained to deliver optimal care. Tailoring the transitional care plan to meet Mrs. Snyder’s specific requirements is essential. This includes providing community-based healthcare services and facilitating rapid information sharing among healthcare professionals (Dyer, 2021).
    6. Community and Health Care Resources: Access to community services, such as mobility options and social support, is vital to prevent negative medical outcomes like hospital readmissions and mortality rates (Yue et al., 2019).

    Insightful Assessment of the Patient’s Needs

    To transfer Mrs. Snyder to another healthcare sector, various information is needed, including medical test results, a list of post-discharge prescriptions, time spent in the previous hospital, counseling documents, follow-up plans, social assistance and insurance coverage documents, current health condition, safety risk assessments, and a comprehensive treatment and drug history related to chronic diseases (Humphries et al., 2020).

    Importance of Key Elements of a Transitional Care Plan

    Each key element is indispensable in transitional care plans to enhance patient care quality. Advance directive information from previous healthcare sectors helps healthcare professionals anticipate potential issues and align treatment accordingly. Community and healthcare resources are vital for addressing Mrs. Snyder’s specific concerns, such as providing facilities for her walking difficulties and ensuring wheelchair accessibility. Medication reconciliation is critical to avoiding errors and addressing Mrs. Snyder’s specific needs, such as precise insulin dosing. Patient feedback guides healthcare providers in delivering personalized and effective care (Borulkar et al., 2022; Fiorillo et al., 2020). Training healthcare professionals and patients is essential for effective collaboration, communication, and improved patient outcomes (Kaper et al., 2019).

    Potential Effects of Incomplete or Inaccurate Information on Care

    Transferring complete and accurate patient information is crucial, as incomplete or inaccurate information can lead to treatment delays, complications, wrong treatments, increased mortality rates, and medication errors (Zirpe et al., 2020).

    Importance of Effective Communication

    Effective communication with other healthcare agencies is necessary for a detailed understanding of patients’ medical history. It fosters a positive interaction between patients and healthcare staff, builds trust, and encourages commitment to care plans (Garcia-Jorda et al., 2022). Effective communication helps in making informed decisions for patient well-being and reduces the chances of adverse events and mortality rates within the organization (Yazdinejad et al., 2020).

    Potential Effects of Ineffective Communications

    Ineffective communication can lead to delayed, untimely, and inappropriate treatments, health disparities, increased treatment costs, decreased patient satisfaction, and compromised patient care quality (Raeisi et al., 2019).

    Barriers to the Transfer of Accurate Patient Information

    Obstacles to sharing accurate information include insufficient staff, incomplete medical histories, lack of knowledge about Electronic Health Records (EHR) technology, and the economic burden of repeated testing due to inadequate planning and information sharing (Ilardo & Speciale, 2020; Cullati et al., 2019; Tsai et al., 2020).

    Strategy to Establish Absolute Understanding of Continued Care

    Strategies to provide effective care include proper planning for information transfer, conducting follow-up sessions to understand patient perspectives, developing collaborative approaches, and providing complete discharge instructions to ensure a smooth transition and improve the quality of care treatment (Glans et al., 2020; Spencer & Singh Punia, 2020).


    A transitional care plan is essential for transferring patients between healthcare sectors, ensuring the transfer of complete medical histories to prevent complications and mortality rates. For Mrs. Snyder, this plan is vital for optimal care and self-management to address diabetes-related consequences. Proper planning and follow-up strategies further contribute to improving the quality of care treatment for patients.


    Moghaddam, M. A.A., Zarei, E., Bagherzadeh, R., Dargahi, H., & Farrokhi, P. (2019). Evaluation of service quality from patients’ viewpoint. BMC Health Services Research, 19(1).

    Blackwood, D. H., Walker, D., Mythen, M. G., Taylor, R. M., & Vindrola-Padros, C. (2019). Barriers to advance care planning with patients as perceived by nurses and other healthcare professionals: A systematic review. Journal of Clinical Nursing, 28(23-24), 4276–4297.

    Borulkar, R., Dhande, P., & Dhande, P. (2022). Medication Reconciliation: A beneficial tool in patient safety 1 1. Bharati Vidyapeeth Medical Journal (BVMJ), 2(3).

    Chen, Y., Ding, S., Xu, Z., Zheng, H., & Yang, S. (2018). Blockchain-based medical records secure storage and medical service framework. Journal of Medical Systems, 43(1).

    Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Junod Perron, N., Bajwa, N. M., Viet Vu, N., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & Nendaz, M. R. (2019). When team conflicts threaten the quality of care: A study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43–51.

    NURS FPX 6610 Assessment 3 Transitional Care Plan

    Dowling, T., Kennedy, S., & Foran, S. (2020). Implementing advance directives—An international literature review of important considerations for nurses. Journal of Nursing Management, 28(6).

    Dyer, E. (2021). It’s about people: Caring agents and satisfied patients are key to a successful healthcare call center culture. Management in Healthcare, 6(2), 134–141.

    Fernandes, B. D., Almeida, P. H. R. F., Foppa, A. A., Sousa, C. T., Ayres, L. R., & Chemello, C. (2020). Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in Social and Administrative Pharmacy, 16(5), 605–613.

    Fiorillo, A., Barlati, S., Bellomo, A., Corrivetti, G., Nicolò, G., Sampogna, G., Stanga, V., Veltro, F., Maina, G., & Vita, A. (2020). The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review. Annals of General Psychiatry, 19(1).

    Garcia-Jorda, D., Fabreau, G. E., Li, Q. K. W., Polachek, A., Milaney, K., McLane, P., & McBrien, K. A. (2022). Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study. BMC Health Services Research, 22(1).

    Glans, M., Kragh Ekstam, A., Jakobsson, U., Bondesson, Å., & Midlöv, P. (2020). Risk factors for hospital readmission in older adults within 30 days of discharge – A comparative retrospective study. BMC Geriatrics, 20(1).

    Humphries, C., Jaganathan, S., Panniyammakal, J., Singh, S., Dorairaj, P., Price, M., Gill, P., Greenfield, S., Lilford, R., & Manaseki-Holland, S. (2020). Investigating discharge communication for chronic disease patients in three hospitals in India. Plos One, 15(4), 0230438.

    Ilardo, M. L., & Speciale, A. (2020). The community pharmacist: Perceived barriers and patient-centered care communication. International Journal of Environmental Research and Public Health, 17(2).

    Kaper, M. S., Winter, A. F. de, Bevilacqua, R., Giammarchi, C., McCusker, A., Sixsmith, J., Koot, J. A. R., & Reijneveld, S. A. (2019). Positive Outcomes of a Comprehensive Health Literacy Communication training for health professionals in three European countries: A multi-center pre-post intervention study. International Journal of Environmental Research and Public Health, 16(20), 3923.

    NURS FPX 6610 Assessment 3 Transitional Care Plan

    Korytkowski, M. T., Muniyappa, R., Antinori-Lent, K., Donihi, A. C., Drincic, A. T., Hirsch, I. B., Luger, A., McDonnell, M. E., Murad, M. H., Nielsen, C., Pegg, C., Rushakoff, R. J., Santesso, N., & Umpierrez, G. E. (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.

    Raeisi, A., Rarani, M. A., & Soltani, F. (2019). Challenges of the patient handover process in healthcare services: A systematic review. Journal of Education and Health Promotion, 8(173).

    Schultz, B. E., Corbett, C. F., Hughes, R. G., & Bell, N. (2021). Scoping review: Social support impacts hospital readmission rates. Journal of Clinical Nursing.

    Spencer, R. A., & Singh Punia, H. (2020). A scoping review of communication tools applicable to patients and their primary care providers after discharge from the hospital. Patient Education and Counseling.

    Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of electronic health record implementation and barriers to adoption and use: A scoping review and qualitative analysis of the content. Life, 10(12), 327.

    Watts, G. F., Gidding, S. S., Mata, P., Pang, J., Sullivan, D. R., Yamashita, S., Raal, F. J., Santos, R. D., & Ray, K. K. (2020). Familial hypercholesterolemia: Evolving knowledge for designing adaptive models of care. Nature Reviews Cardiology, 17(6), 360–377.

    Yazdinejad, A., Srivastava, G., Parizi, R. M., Dehghantanha, A., Choo, K.-K. . R., & Aledhari, M. (2020). Decentralized authentication of distributed patients in hospital networks using blockchain. IEEE Journal of Biomedical and Health Informatics, 24(8), 2146–2156.

    Yue, D., Pourat, N., Chen, X., Lu, C., Zhou, W., Daniel, M., Hoang, H., Sripipatana, A., & Ponce, N. A. (2019). Enabling services to improve access to care, preventive services, and satisfaction among health center patients. Health Affairs, 38(9), 1468–1474.

    Zirpe, K., Seta, B., Gholap, S., Aurangabadi, K., Gurav, S. K., Deshmukh, A. M., Wankhede, P., Suryawanshi, P., Vasanth, S., Kurian, M., Philip, E., Jagtap, N., & Pandit, E. (2020). Incidence of medication error in critical care unit of a tertiary care hospital: Where do we stand? Indian Journal of Critical Care Medicine, 24(9), 799–803.