A case scenario for a patient who experiences transitions across three points of healthcare delivery

A case scenario for a patient who experiences transitions across three points of healthcare delivery

A case scenario for a patient who experiences transitions across three points of healthcare delivery. For example, a patient who is admitted through the Emergency Department rushed to surgery and transferred to the surgical intensive care unit; or a patient who transitions from an assisted living facility to the hospital and then to a long-term acute care facility. These are just two examples. However, you can be creative as you create the case scenario.

 

Leading Person-centered Care

Part 1: Case Scenario

Judy, a terminally ill patient, was suffering from the final stages of pulmonary fibrosis one nightlight; Judy experienced difficulties in breathing and was rushed to the hospital emergency room. The doctor discovered that Judy had pneumonia and gave her oxygen, steroids, and antibiotics, but his condition did not improve. Judy was transferred to inpatient so that the doctor could observe her progress. After observing her situation for a few days, the doctor finally recommended that the best way to deal with Judy’s condition was to go through palliative care or use a mechanical ventilator.

 

Judy did not like the idea of her final days undergoing life support, so she chose home-based care to spend her last days with her family. The nurse assigned to Judy could advise her family on how best they would like to care for Judy’s needs through home-based care. Judy was sent home with prescriptions for different medications and oxygen. Judy’s family was referred to hospice personnel, who would help them coordinate home-based care and help with the filling of drugs. The nurse assigned to Judy and his family would also avail herself to assist Judy when she experienced any health challenges.

 

Introduction

One of the significant vulnerabilities of the healthcare system is the transition of care across different healthcare delivery points due to the increased occurrence of medical errors and clinical deterioration. The transition of care refers to the various points that patients move to contact health care professionals to receive medical services as their conditions and needs of care change (World Health Organization, 2016), for example, shifting from the emergency department to the patient.

 

Effective transition involves the coordination and collaboration of different healthcare professionals and the patient’s engagement to facilitate the safe and timely delivery of patients to the various transition points. Poor transition care leads to increased chances of readmission and a higher cost of care.

 

Transitions in point of care delivery

A case scenario for a patient who experiences transitions across three points of healthcare delivery

  • Explain the transitions in point of care delivery portrayed within the case scenario.
  • Discuss the variables that could impact safety, quality, and continuity of care for the transitions described.
  • Identify one specific patient outcome for each transition, and explain why that outcome is appropriate.
  • Identify one evidence-based strategy to support outcome achievement and person-centered care for each transition.

Transitions in point of care delivery

In the case scenario, the patient Judy experienced transitions across three points of healthcare delivery; first, the patient was admitted through the emergency department after she experienced difficulties in breathing as a result of pneumonia. She was then transferred to inpatient because her condition did not improve, and finally, the patient was transferred to home-based palliative care.

 

 

Some of the factors that could affect safety, quality, and continuity of care for the transitions include poor communication. The healthcare professionals in charge of taking care of a patient do not communicate effectively or share vital information (Delboccio et al., 2015).

For example, in the case of Judy, if the nurse in charge of coordinating home-based palliative care does not provide the family with appropriate information on how the family can take care of the patient, it could lead to the patient’s premature death (Josephson, 2016).

Judy was admitted to the emergency department after experiencing difficulty breathing; the physician dealing with her case was aware that she was at her end-stage pulmonary fibrosis; therefore, she had adequate information to deal with her issue appropriately.

After being admitted to the inpatient and diagnosed with pneumonia, Judy received two medical recommendations for her condition: palliative care or intubation and a mechanical ventilator.

The outcome of Judy’s transition from the emergency department to home-based palliative care was smooth because the health professionals in charge of her case were aware of her preexisting condition, and she was provided an appropriate medical recommendation for her condition.

 

 

A case scenario for a patient who experiences transitions across three points of healthcare delivery: The role of the nurse is to ensure high-quality, person-centered points of care delivery

 

A case scenario for a patient who experiences transitions across three points of healthcare delivery

Nurses are essential in facilitating the transition from the hospital setting to palliative care by providing emotional support to the patient and his family and managing all the tasks required to facilitate a smooth transition (Camicia & Lutz, 2016). Nurses also develop and evaluate the care transition plan to eliminate communication barriers. One of the care coordination principles includes collaborating and engaging the patient and their families to attain the desired outcome.

 

The second principle is applying professional communication to enhance patient-centered care. The transition of care is a vital process within the healthcare delivery system. It requires the coordination and collaboration of different health professionals and the patients’ engagement for the process to be a success. Ineffective management of the transition process could negatively impact a patient’s health.

 

 

References

Camicia, M. & Lutz, B. J. (2016). Nursing’s role in successful transitions across settings. Stroke, 47(11) e246-e249. https://doi.org/10.1161/STROKEAHA.116.012095 Clinical Practice. 6(2): 183-189.

Josephson, S. A. (2016). Focusing on transitions of care. Neurology

Delboccio, S., Smith, D. F., Hicks, M., Lowe, P., V., Graves-Rust, J. E., Volland, J. & Fryda, S. (2015). Success and challenges in patient care transition programming: One hospital’s journey. The Online Journal of Issues in Nursing, 20(3). https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/O

World Health Organization. (2016). The transition of care: Technical series on safer primary care. https://apps.who.int/iris/bitstream/handle/10665/252272/9789241511599-eng.pdf? sequence=1