Comprehensive Health Assessment of Patients and Populations Essay Example

Transition of Care for a 55 Year-Old Hispanic Male treated for Acute Myocardial Infarction (AMI)

According to Zangerle et al. (2016), care transition is the totality of actions taken and activities done to safely transfer a patient from one care setting to another (or home). This is done in a manner not to break the care continuum as the move is made from the previous care setting to another or the home. If not managed properly, things like misunderstanding of instructions at discharge may result in medication noncompliance (to dosing, to frequency, or to duration) and poor therapeutic outcomes. These poor outcomes then result to unnecessary readmissions to hospital. It is therefore clear that care transition can be costly to the patient and the organization if not well thought out and planned (Werner et al., 2016; Abrashkin et al., 2012; Fuji et al., 2012). It has been argued before that care transitions are the weakest point in the care continuum and may be the source of breakdown in care even after significant gains have been made. Transition of care is more complex than mere clinical handing over of a patient from one care setting to another. It is broader and involves consideration of the fact that the patient is being moved from one setting to another (or home) in which they may not benefit from the services they got in the previous care setting (WHO, 2016). To make sure that care transitions happen in an organized way and systematically, there needs to be a dedicated patient care transition coordinator (PCTC). The purpose of this paper is to outline the role played by the PCTC in three phases with regard to the care transition of a 55 year-old Hispanic male treated in the hospital for acute myocardial infarction (AMI) for 5 days.    Comprehensive Health Assessment of Patients and Populations Essay Example

Phase 1: Evidence-Based Transition Practices and Care Transition Plan

As a patient care transition coordinator, I am responsible for assisting this patient to transition his care smoothly from the hospital as an inpatient to their home and for cardiac rehabilitation. As this 55 year-old patient transitions from being an inpatient in the hospital to the home environment, the most important goal is to prevent his rehospitalization or readmission within the first 30 days of discharge. To do this effectively, a plan of care to bridge care gaps comprising of evidence-based practices (EBP) in care transition is put in place. This will include:

  1. Patient health education (prevention of adverse drug events or ADEs after discharge, adherence to medications, compliance, and personal responsibility for care)
  2. Secondary prevention strategies for myocardial infarction (Hammer & McPhee, 2018), including advice and education on behavioral/ lifestyle changes (regular isotonic aerobic exercise, regular diet with enough fresh fruits and vegetables, reduction in the consumption of junk foods/ coke), and explanation of the role of each medication and why they are important in the prevention of a second MI (aspirin/ beta-blockers/ ACE inhibitors).
  • Arrangement with the social worker for home visits
  1. Booking the patient for telemedicine to allow them to have a live consultation from their home when they have a concern.

One of the most common causes of readmissions after discharge is the occurrence of adverse drug reactions (ADRs). These occur as a result of several reasons; chief amongst them being that the patient did not receive comprehensive instructions on how to use them at discharge. For this reason, the plan will include teaching the patient adequately about adhering to medications and the importance of that. It will also include educating the 55 year-old patient about compliance to treatment and its impact to recovery and prevention of readmissions. Finally, it will include telling the patient categorically that they must assume personal responsibility for their care if they are to prevent unwanted readmissions. The next part of the plan will be to give the patient sound advice on secondary prevention of a subsequent MI. This will include asking them to start doing the walking or isotonic aerobic exercise six days a week rather than once every week (Yoshinaga et al., 2018), stopping the habit of eating junk foods at fast food outlets and eat home-prepared foods more, and eating a regular diet of foods rich in fresh fruits and vegetables. The advice will also include education on medication given at discharge – what they are, what they do, and why it is crucial that they take them and continue taking them without stopping. Arrangements will be made with the social worker to make home visits and assess whether the post-discharge period is safe. Lastly but not least, he will be enrolled for telehealth services such that he will be able to get live consultation from home any moment he feels that he is not doing well.


Phase 2: Preventing All-Cause Non-Disease Specific Readmission Rates

As the patient care transition coordinator, I will during this second phase concentrate on dealing with non-disease specific causes of readmission of AMI patients within 30 days after discharge. These factors are non-disease specific because they cut across all discharges regardless of the disease or condition that the patient has. In this particular case, they will include:

  1. Poor care coordination after the patient is discharged from the hospital
  2. A failure, unwillingness, or inability to follow instructions and orders issued at discharge

The patient who is discharged after surviving acute MI is a patient who must be watched closely. They must also have a sufficient social support system that will enable him to be reminded to take his medication or go for his walk for instance. Being above the age of 50 years, it is expected that this patient will have periods when he will forget that he needs to take medications or go for a walk. This is a normal occurrence especially given that the patient will be feeling well and may wonder why he still needs to take the medications. Intense but simplified education will then be given to the patient and a chosen caregiver from the family who will coordinate his care.

As for the instructions given at discharge, enough education on why the orders need to be followed even if the patient is feeling well will be given. It will be made clear to them and their caregiver that the medications such as atorvastatin and aspirin for instance will not be treating the current condition, but will be preventing a potentially deadlier subsequent MI that they might not survive. For this reason alone, he will be required to stick to the instructions given at discharge. Luckily, this patient has an extended family that is close to them and that checks on them from time to time. Therefore, this patent will not lack the kind of social support system an MI survivor would need.

Phase 3: Hospital Prevention Plan

In this phase, I as the PCTC will concentrate on holistic prevention efforts that will have the effect of keeping the patient out of the hospital. To begin with, the focus will be on the main modifiable MI risk determinants such as a sedentary lifestyle, obesity, and hyperlipidemia amongst others. This patient has all of these three conditions and only one is being managed (hypertension). His hyperlipidemia (high serum lipid levels, especially low-density lipoprotein or LDL-Cholesterol) is not managed and yet it is a major facilitator of the development of MI. He will now be advised on transition to start being compliant with the discharge medications that will take care of this (Herndon et al., 2012; Weaver, 1999). This patient also has another risk factor in the form of obesity. A calculation of his body mass index or BMI using the weight and height given in his medical notes reveals that he has a BMI of 35.2 kg/m2. This combined with his relatively sedentary lifestyle and a penchant for fast foods places him at a very high risk of suffering a deadlier subsequent MI. A lot of education effort will therefore be put in helping this patient reduce his weight via the secondary prevention strategies already outlined above (particularly exercise and dietary modifications).

Lastly but not least will be some education and assistance on tertiary prevention of the MI. This includes making arrangements for the patient’s cardiac rehabilitation program (Contractor, 2011) and linking them with available support groups of those who have survived MI and are currently convalescing and undergoing rehabilitation.    Comprehensive Health Assessment of Patients and Populations Essay Example


Abrashkin, K.A., Cho, H.J., Torgalkar, S., & Markoff, B. (2012). Improving transitions of care from hospital to home: What works? Mount Sinai Journal of Medicine, 79(5), 535–544.

Contractor, A.S. (2011). Cardiac rehabilitation after myocardial infarction. The Journal of the Association of Physicians of India, 59(Suppl), 51-55.

Fuji, T., Abbott, A.A., & Norris, J.F. (2012). Exploring care transitions from patient, caregiver, and health-care provider perspectives. Clinical Nursing Research, 22(3), 258-274.

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.


Herndon, L., Bones, C., Kurapati, S., Rutherford, P., & Vecchioni, N. (2012).  How-to guide: Improving transitions from the hospital to skilled nursing facilities to reduce avoidable rehospitalizations. Institute for Healthcare Improvement.

Yoshinaga, M., Seki, S., Ogata, H., Ito, Y., Aoki, M., Miyazaki, A., Tokuda, M., Lin, L., Horigome, H., & Nagashima, M. (2018). Treating childhood obesity by walking: A randomised controlled trial. Circulation, 136(Suppl. 1).

Weaver, F.M., Perloff, L., & Waters, T. (1999). Patients’ and caregivers’ transition from hospital to home: Needs and recommendations. Home Health Care Services Quarterly, 17(3), 27-48.

Werner, N.E., Gurses, A.P., Leff, B. & Arbaje, A.I. (2016). Improving care transitions across healthcare settings through a human factors approach. Journal for Healthcare Quality, 38(6), 328–343.

World Health Organization [WHO] (2016). Transitions of care: Technical series on safer primary care.;jsessionid=18835745F81D91E258BFF7B409AF48D1?sequence=1

Zangerle, C. & Kingston, M.B. (2016). Managing care coordination and transitions: The nurse leader’s role. Nurse Leader, 14(3), 171-173.

Welcome to the Clinical Practice Experience (CPE) for this course. The CPE for the Master of Science in Nursing program core courses consists of a variety of semi-structured activities. CPE provides the opportunity to integrate new knowledge into practice and to attain the identified professional competencies (AACN, 2016).  By completing all the activities and evidence listed within this document, and earning a grade of “Competent,” you will earn 40 indirect CPE hours for this course.*

CPE Objective:

In this CPE, you will experience the role of a graduate degree prepared nurse who is a Patient Care Transition Coordinator. For the purpose of this CPE, a Patient Care Transition Coordinator is defined as a nurse who focuses on assisting patients moving from the hospital to a rehabilitation facility, and then to their homes. During this experience, you will help specific patients move through different levels and types of care. You will identify the education, experience, and skills required for you to perform this role successfully. Additionally, as a Patient Care Transition Coordinator, you should aim to prevent hospitalization and rehospitalization of patients who returned to their homes after hospitalization and rehabilitation.

In this CPE, you will experience the role of a graduate degree-prepared nurse in three phases:

  • Phase 1: You will examine evidence-based practices regarding transitions of care for a patient experiencing one of the conditions or procedures identified in the CMS Hospital Readmissions Reduction Program (HRRP) (acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia, coronary artery bypass surgery (CABG), & elective primary total hip arthroplasty and or total knee arthroplasty (THA/TKA) ) and focus on the complications specific to the selected condition or procedure discussed in the case. You will choose one patient to focus on for all three phases of the CPE from the cases provided in the Advanced Health Assessment of Patients and Populations CPE Case Scenarios document.
  • Phase 2: Again, you will examine evidence-based practices regarding transitions of care for patients transitioning from hospital (or rehabilitation unit) to home. Yet in this phase, there will be a specific focus on reducing all-cause, non-disease specific readmission rates. You will add this knowledge to the CMS HRRP condition or procedure that was chosen in phase 1, which focused on transitions of care practices specific to one condition or procedure. In this phase, you will focus on reducing the potential causes of readmission that are not related to the condition or procedure of interest.
  • Phase 3: You will once more examine evidence-based practices regarding transitions of care. For this phase, you will focus on the prevention of hospitalization for patients who are at risk for developing the HRRP condition or procedure chosen in phase 1. You will develop an evidence-based plan for primary, secondary, and tertiary prevention of the condition or procedure of interest.

Student Instructions:

  • Complete and date the required activities
  • Type in your name and date the top of this form
  • Type in the name of your faculty of record for this course (your assigned Course Instructor)
  • Submit the completed CPE Record for evaluation

Comprehensive Health Assessment of Patients and Populations Essay Example




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