he World Health Organization (2016) emphasizes the importance of a system of transition of care because “transitions from one care setting to the next are often accompanied by changes in health status.” A healthcare leader must have a plan in place to make these transitions as smooth as possible. Feeley (2017) reminds nurse leaders that patients are the main focus of the Quadruple Aim, so you must prepare for change with this in mind. Annotated Bibliography on Transitions of Care Essay
This Assignment focuses on your leadership goal of keeping patients at the forefront of any change, including transitions.
References
Feeley, D. (2017, November 28). The triple aim or the quadruple aim? Four points to help set your strategy [Blog post]. Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy
World Health Organization. (2016). Transitions of care: Technical series on safer primary care. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/252272/9789241511599-eng.pdf;jsessionid=18835745F81D91E258BFF7B409AF48D1?sequence=1
To prepare:
Review feedback on your Week 4 Assignment. You should incorporate your Instructor’s feedback and continue to add to and refine your annotated bibliography for your selected transition of care.
Consider the nurse leader’s role in achieving the IHI Quadruple Aim for this transition of care. (Hint: Draw from resources on systems thinking and nurse leaders’ ability to influence innovation and change.)
Assignment (5–6 pages, not including title and reference page):
Write a paper in which you address the following:
Identity your selected example of a transition of care.
Describe the key stakeholders that might be involved in this transition of care and the leadership strategies you would use to engage and influence them.
Explain how you, as a nurse leader along with your healthcare team, would apply systems thinking when providing a transition of care aligned with the IHI Quadruple Aim framework in order to improve it. Explain the fourth aim and strategy you would use and why.
Explain how systems thinking would inform your improvement plan for the specific transition of care you selected.
Be sure your paper includes a title page and a reference page. You should also resubmit your refined Annotated Bibliography.
System of Transition of Care
Introduction
The transition of care from a hospital setting to a nursing home setting is a multifaceted phenomenon that is influenced by numerous interacting factors, that include the health, individual, and environmental factors. Improving the experience of care during the transition of care from a hospital setting to a home care setting involves care that is effective, safe, efficient, patient-centered, and equitable. Nurses have a critical role to play during the transition of care because they are constantly in contact with patients and hence the nurse leader has the role of ensuring that all aspects of care transition are addressed in a coordinated and comprehensive manner (Mery et al., 2017). This assignment will discuss the role of a nurse leader in attaining the IHI Quadruple Aim for a transition of care from a hospital setting to a nursing home setting. Annotated Bibliography on Transitions of Care Essay
The key stakeholders involved in the transition of care from a hospital setting to a nursing home setting include the patient, family, physicians, staff nurses, pharmacists, home care nurses, and social workers (Richardson et al., 2019). First, the patient needs to be actively involved during the transition of care. the patient requires multidisciplinary interaction with the healthcare team involved in the care transition. In addition, the patient needs to actively participate in the financial and insurance aspects involved during care transition, as well as in being informed about the necessary medical appointments and treatment regimen. The family also needs to be actively involved in a successful transition. According to Richardson et al (2019), the family members are key team members during care transition and hence should be actively involved in resident transitions. The RN staff in the hospital play the major role during the transition of care because they are involved in aspects such as the discharge, handling patient education and the prescribed medications, as well as handing over the care to the respective parties in the nursing home staff (Lee et al., 2013). Therefore, nursing home nurses are involved in the handover process from the hospital staff nurses. Pharmacists and physicians are also actively involved in the care transition especially in making major decisions in issues such as medication dispensing and prescriptions respectively. The social worker has the role of addressing social-service issues involved in the care transition, relieving care burden and helping patients and their families to cope with changes regarding health status and connecting patients with services prescribed and ordered during discharge and transition of care.
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The leadership strategies that would be used to engage and influence the key stakeholders include using effective communication and teamwork. In order to ensure a safe transition of care, the nurse leader should establish comprehensive communication with all the involved team members. This means making sure that each relevant stakeholder has the required information and establishing the required communication channels, among all stakeholders. Teamwork involving comprehensive and effective communication and collaboration among the stakeholders in the care transition is important in order to ensure the successful transition of ongoing care across care settings (Wei et al., 2018). Teamwork involves a shared purpose and associated incentives among all relevant stakeholders in the care transition, who should work as a united patient‐centered network. This is because dysfunctional teamwork leads to fragmented care and hence the nurse leader should ensure effective care coordination, communication, and provision of adequate feedback to and from the relevant transitioning institutions regarding patients. The nurse leader should also ensure that the patient and the family are fully educated about the health needs of the patient in order to ensure the successful execution of the care plans (Richardson et al., 2019).
System thinking during the transition of care involves addressing all multifaceted interacting factors that affect the health of the patients and the process of care transition. Therefore, as per the Triple Aim, the process of care transition should involve improving the quality of care, improving the population’s health and reducing the cost of care (Feeley, 2017). Provided the continuous contact of nurses with the patients, nurses have a major role in improving the patient experience. This can be achieved by ensuring that the care transition is done comprehensively and harmonized. Effective communication and coordination can significantly improve the transition of care for the patient and prevent errors and inefficiencies that could occur. Triple Aim also focuses on reducing the cost of healthcare in the population, to ensure that resources are utilized on more needy initiatives (Bowles et al., 2018). The nurse leader makes decisions regarding various aspects of resource use, that include use of equipment and preparations during care transition. This can increase the costs dramatically for the population or the individual patient, and therefore the nurse leader is in a prime position to reduce the associated cost.
The fourth aim involves the nurse leader is the patient advocate and be innovative during the provision of care. The nurse leader can achieve this by promoting healthy work environments by reducing the work overload, addressing safety concerns and toxic work atmosphere (Bodenheimer & Sinsky, 2014). The nurse leader should, therefore, implement strategies such as effective communication, true partnership and collaboration, suitable nurse staffing, meaningful recognition of the nurses, and effective decision-making (Batcheller et al., 2017). This can promote a good work environment that can be a motivating factor for the nurses. Nurses who are satisfied with their work are likely to cooperate and collaborate well during the transition of care. The strategy a nurse leader should use include ensuring that the staff involved in the transition of care are satisfied with the work environment Bodenheimer & Sinsky, 2014). This involves the nurse leader using appropriate leadership styles such as transformational leadership style. This because the transformational leadership style has been shown to motivate and inspire workers. Therefore, the nurse leader can consider using the appropriate leadership style during care transition. Moreover, leadership styles such as transformational have been shown to be effective in improving the quality of care and patient safety.
Systems thinking is very essential to quality improvement. A shared purpose and unified purpose can allow nurses and other healthcare providers during the transition of care to come together, and this ensures that all energy and efforts are directed towards attaining the single goal of the safe transition of care. Systems thinking is likely to create a culture of continuous improvement and also instill a sense of providing quality care and learning in order to make improvements (World Health Organization, 2016).
Therefore, during transition of care from a hospital setting to a nursing home setting, the systems thinking can ensure that that there is a shared goal among all involved stakeholders such as the patient, family, physicians, staff nurses, pharmacists, home care nurses, and social workers (Richardson et al., 2019). The system thinking is likely to assist in the provision of better and improved patient-centered care, promote problem-solving and inspire questioning. For instance, during the transition of care for patients from a hospital setting to a nursing home setting, patients can be helped by ensuring that patients have support in place to ensure they adhere to the treatment plan (World Health Organization, 2016). The nurses in the hospital setting should consult with the nursing staff in the nursing home as well as the specific nurse care managers for the patients and ensure that they are provided with the appropriate information and copies of discharge plans for the patients. This ensures that the healthcare providers who receive the patients dully understand the care plans for the patients and their discharge plans as well. In addition, it is important for the nurse leader to facilitate direct communication between all parties involves in patients’ transition of care and update all parties regarding the patients’ progress. Finally, the nurse leader could implement visiting rotations to the nursing homes after patients are discharged from a hospital setting in order to provide any needed information and also monitor the progress of the patients (Britton et al., 2017). Annotated Bibliography on Transitions of Care Essay
Conclusion
The key stakeholders involved in the transition of care from a hospital setting to a nursing home setting include the patient, family, physicians, staff nurses, pharmacists, home care nurses, and social workers. The transition of care from a hospital setting to a nursing home setting is a multifaceted phenomenon influenced by numerous interacting factors. Therefore, systems thinking ensures that all the multiple factors involved in the care transition are addressed. The use of effective communication and teamwork can significantly improve care transition because it ensures that all involved stakeholders in the care transition collaborate and have the required information during the transition of care.
Management of transition of care refers to the activities and services designed to facilitate continuity of care and eliminate preventable poor outcomes and promote safe and timely transition of care from one level of care to another, or from one healthcare setting to another. Nurse leaders are advocates and collaborators with abilities and skills to ensure successful coordination of care and transition management. Transition and coordination of care succeed when there is effective interprofessional collaboration. Nurse leaders play an important role in ensuring coordination of efforts during care transition. This assignment will provide an annotated bibliography on five journal articles addressing the transition of care from one healthcare institution to another.
Lefebvre H, Brault I, Roy O, Levert M, Dan L, & Proulx M. (2018). Partnership between patients, nurse leaders, and researchers: Outcomes of a web-based KT strategy for hospital discharge planning and care transitions in oncology. Can Oncol Nurs J, 28(2), 110–117.
The article presents a web technology developed by nurse leaders, patient partners, and researchers from six different clinical settings. The web technology was developed and tested using the Forum for Knowledge Exchange (FKE), with the aim of improving discharge planning practices and the transition of oncology care. The latest evidence supports the use of technology to improve care practice and patient care and therefore the integration of web technology to improve care practice and care transition in this article is very relevant and valid. Authors provide a strong argument of how the development of web technology has helped bedside nurses, senior management, clinical decision-makers, patients, families and other stakeholders to be able to directly contact and synchronously engage and communicate with each other. The web technology-facilitated easy access to information and documentation and allowed effective collaboration during the discharge planning and transition of care in the oncology sector. The article thus provides important information on how nurse leaders can support the implementation of the most recent technologies to improve care transition. Annotated Bibliography on Transitions of Care Essay
Britton M, Ouellet G, Minges K, Gawel M, Hodshon B & Chaudhry S. (2017). Care Transitions Between Hospitals and Skilled Nursing Facilities: Perspectives of Sending and Receiving Providers. The Joint Commission Journal on Quality and Patient Safety,2017(3), 565–572.
The article presents an investigation of are the transition of care between hospitals and skilled nursing facilities. In this article, various healthcare providers were interviewed to give information regarding care transition between these healthcare facilities. According to the article, the readmission rate of Medicare patients admitted for acute illnesses and discharged to a skilled nursing facility is very high. 23% of these patients are readmitted to within 30 days. The nurse director and other healthcare providers attributed this to the poor transition of care from hospitals to skilled nursing facilities. According to the nurse, leader interviewed in a skilled nursing facility, some of the reasons attributable to the poor care transition include lack of an adequate number of nursing staff to attend patients and lack of synchronization between hospital and skilled nursing facility during care transition. This makes it difficult to address patient care needs after the transition of care.
This article provides important information about care transition across the care continuum by concluding how the transition of care can be improved by improving communication between healthcare providers, ensuring provider understanding of post-acute care, and aligning facilities. The article concludes by recommending that care transition can be improved by developing direct communication channels between providers involved in the care transition, effective collaboration, and implementing visiting rotations to healthcare facilities aftercare transition. Annotated Bibliography on Transitions of Care Essay
Sorkin D, Amin A, Weimer D, Sharit J, Ladd H & Dana M. (2017). Hospital discharge and selecting a skilled nursing facility: A comparison of experiences and perspectives of patients and their families. Prof Case Manag, 23(2), 50–59. Annotated Bibliography on Transitions of Care Essay
The article presents experiences of patients and their families regarding the discharge process and transition of care from hospital to a skilled nursing facility. The perspectives of the patients and their families indicate the quality of the transition of care. This study is supported by previous studies because patients are important decision-makers during the discharge process and therefore hospital policies should support patient and family involvement in the discharge process. This article is relevant because discharge planning activities include the health care team, and especially the nurse discharge planners and care managers and include assessment of if the patient’s discharge should be directly home or to another care facility. Moreover, the discharge planning process normally necessitates patient involvement and their family members as well. Leaders in healthcare settings like nurse leaders inwards and care homes are the most influential individuals on the behavior of the staff. This article, therefore, provides important information regarding the importance of including patients and their families in the discharge process. Nurse leaders, therefore, have the role of implementing organizational culture and suitable changes in their settings in order to ensure a smooth transition of care and satisfaction for patients and their families as well.
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Baxter R, O’Hara J, Murray J, et al. (2018). Partners at Care Transitions: exploring healthcare professionals’ perspectives of excellence at care transitions for older people. BMJ Open, 2018(8), e022468. doi: 10.1136/bmjopen-2018-022468.
The article sought to investigate how healthcare providers support the care transition of patients from hospital to home for older adults. In this study, healthcare providers from six well-performing hospitals participated in the study to explore how the healthcare team effectively provide care to ensure the successful and safe transition of care and how they overcome challenges during care transition. The article argues that patients leaving hospitals require ongoing care because the transition period is risky, and especially for older adults having complex social care and health care needs. The study focuses on factors facilitating safe outcomes after the transition of care. The study seeks to investigate how healthcare providers in high-performing teams effectively support the transition of care from hospital to home for older adults. The article is relevant for the research topic because it provides up-to-date information on how successful transition of care from hospital to home care can be facilitated by healthcare providers. Annotated Bibliography on Transitions of Care Essay
Oikonomou, E., Chatburn, E., Higham, H. et al. Developing a measure to assess the quality of care transitions for older people. BMC Health Serv Res, 19(05), doi:10.1186/s12913-019-4306-8.
The purpose of this article was to develop a measurement tool for care transition in order to assess the patient experience of the transition process as a marker of the quality of transition of care. Therefore, the authors of the article developed a framework of key elements of the transition of care from hospital to home and developed a measure to assess the safety and quality of transition of care for older patients. The components that were assessed in regard to the transition of care included patient involvement; medication management; and information sharing. These elements are important to identify any potential problems after hospital discharge. This information could be valuable for the healthcare providers taking part in the discharge planning and hospital units aiming to improve safety and care continuity for the older patients. The article is relevant for the research topic because it provides information regarding some of the important components of care transition. Nurse leaders should focus on improving such components in order to ensure a successful and safe transition of care from hospitals to home care institutions.
Summary
This assignment provided an annotated bibliography of five selected journal articles on transition of care. The selected articles addressed issues such as care transition from one healthcare institution to another; factors that can facilitate the successful transition of care; approaches to improve and ensure a safe transition of care; as well as how technology can facilitate the successful transition of care.
References
Baxter R, O’Hara J, Murray J, et al. (2018). Partners at Care Transitions: exploring healthcare professionals’ perspectives of excellence at care transitions for older people. BMJ Open, 2018(8), e022468. doi: 10.1136/bmjopen-2018-022468.
Britton M, Ouellet G, Minges K, Gawel M, Hodshon B & Chaudhry S. (2017). Care Transitions Between Hospitals and Skilled Nursing Facilities: Perspectives of Sending and Receiving Providers. The Joint Commission Journal on Quality and Patient Safety,2017(3), 565–572.
Lefebvre H, Brault I, Roy O, Levert M, Dan L, & Proulx M. (2018). Partnership between patients, nurse leaders, and researchers: Outcomes of a web-based KT strategy for hospital discharge planning and care transitions in oncology. Can Oncol Nurs J, 28(2), 110–117.
Oikonomou, E., Chatburn, E., Higham, H. et al. Developing a measure to assess the quality of care transitions for older people. BMC Health Serv Res, 19(05), doi:10.1186/s12913-019-4306-8.
Sorkin D, Amin A, Weimer D, Sharit J, Ladd H & Dana M. (2017). Hospital discharge and selecting a skilled nursing facility: A comparison of experiences and perspectives of patients and their families. Prof Case Manag, 23(2), 50–59. Annotated Bibliography on Transitions of Care Essay