All references need to be < 6 years old. Mostly nursing journals

3. Write Essay (50 points) • Limited to 1000 words for the body of the paper. (One point may be deducted if you go over.) • Include a title page & references – these are not included in the word count. • APA format (cover page, running head, headers, reference page, etc.) Essay Content/Format I. Catchy Introduction
2 | Page

II. Body – (each section is worth 10 points) 1. Summarize TC process from assigned reading-define TC, describe growing problem with aging population, impact, etc. 2. Reflect on the many specific organizations, strategies & outcomes identified in the CAYC videos. 3. Summarize the Interview –introduce the person, summarize questions/responses with focus on challenges/facilitators/barriers to the TC process. 4. Reflect on the role the BSN/gerontology specialist contributes to the transitional care process III. Conclusion. Transitional Care (TC) Project Essay Example

TC Essay Grading Rubric Essay Content / Format Points Possible
Excellent

Competent Developing Points Awarded
Introduction 2 Catchy, identifies purpose & main points 2
Lacks attention grabbing quality or does not include purpose or main points 1-1.5
Lacks attention grabbing quality and no purpose/main points 0-1

Transitional Care (TC) Project

Introduction

The frail older population has multiple health problems, as well as age-related problems and therefore they frequent health facilities; accordingly, the elderly experience care transition often. Effective and efficient care transition is essential because it ensures continuity of care and promotes better health outcomes.  The ineffective and poor transition is associated with poor health outcomes and high rates of readmissions. Accordingly, the focus of this paper is to provide a critique of transition of care for the aging population, reflect on strategies within the CAYC Videos, provide a summary of the interview, and finally analyze the role of the gerontology specialist to the transitional care process.

The Transition of Care & the Aging Population

Care transition refers to the actions intended to facilitate the coordination and continuity of care when patients are transferred to different locations, for instance from the hospital setting to home. Communication and collaboration between healthcare providers, resources’ coordination, and education and participation of patients and the family have been identified as fundamental elements of ensuring quality in care transition (Hirschman & Hodgson, 2018).

High-quality transitional of care is particularly vital for the elderly population with chronic conditions, along with complex treatment regimens, and for their family caregivers as well. Older adults are provided care by numerous healthcare providers and normally frequent healthcare settings. Evidence indicates that the elderly are very susceptible to breakdown in care and hence they have the utmost prerequisite for transitional care services.  The poor transition of care for older patients is associated with adverse events, and high readmission rates (Storm et al, 2014).

There are numerous factors that result in poor care during the transition of older people. Poor communication, poor information transfer, ineffective discharge education of the older patients and their family caregivers, as well as lack of a single point individual to facilitate continuity of care,  have been attributed to the poor transition of care (Baillie et al, 2014).

In most cases, older people lack the capacity to effectively care for themselves due to physiological changes associated with aging and medical conditions that can hinder them from performing activities of daily living. Therefore, family caregivers have a major role when it comes to supporting the older people after the transition from hospital to home setting. It is therefore important to ensure that caregivers to the elderly are actively engaged regarding discharge plans and they are fully prepared to transit to home care setting (Threapleton et al, 2017).

Reflection on Strategies in the CAYC Videos

From the CAYC videos, collaboration between primary care providers, patients, and caregivers is among the most effective strategies to ensure an effective transition of care for the elderly. This is because effective coordination between these different players ensures seamless transition because team members work together. For example, it is important for the healthcare providers to ensure that the patient and the family caregiver are actively involved during the discharge process to ensure that before transition to home setting the caregiver and patient understand the treatment regimen and adhere to it in order to ensure optimal health outcomes (Baillie et al, 2014).

Another strategy is to provide a supportive environment to patients and caregivers as they transit. For instance, doctors, nurses, and social workers should attend to the needs of patients as well as needs of the caregivers during the care transition process in order to reduce negative experiences and improve the ability of caregivers to support their patients. CAYC videos also recommend GPs and social workers supporting patients after the transition of care. For example, social workers may visit patients in their home setting after discharge to monitor their progress and their adherence to the treatment regimen. The social workers and other health care providers can also help patients to attend appointments and follow-up; this can be done through home visits or phone calls to caregivers and patients to remind them about the clinic appointments (Luxford et al, 2017).  Transitional Care (TC) Project Essay Example

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Comprehensive discharge process is another important aspect to facilitate the successful transition of care. During discharge, it is important to engage patients and their caregivers and ensure they understand the discharge information. Additionally, the CAYC videos also suggest that discharge education should be recorded to ensure that after discharge patients and caregivers can watch and listen to the discharge instructions. Other materials such as hospital websites should be provided during discharge to make information available to patients and caregivers in the home setting.

Finally, CAYC videos emphasize the importance of connecting patients with community resources after discharge to facilitate the transition of care.  For instance, social workers and community care agents can be very helpful after hospital discharge by monitoring adherence to medication and facilitating follow-ups (Baillie et al, 2014).

Interview Summary

An RN-discharge planner with the responsibility for coordinating the discharge process for patients was interviewed. Questions covered care continuity and transition, policy and governance, multi-disciplinary team, communication, patients’ case management, as well as discharge planning and needs assessment for care. According to the RN-discharge planner, some of the facilitators to the effective transition of care include connected service networks to ensure continuity of care after the transition. Coordinated care and effective communication also facilitate effective care transition. Additionally, there is a need to have a case manager for coordinating personalized patient care and coordinating with other healthcare providers. Moreover, the comprehensive geriatric assessment was quoted as being effective in ensuring needs assessment and facilitating the development of personalized care plans.  However, inadequate communication, poor coordination, lack of organizational policy on discharge process and care transition, as well as lack of adequate community resources were mentioned as being the major barriers to the successful transition of care.

The Role of the Gerontology Specialist to the Transitional Care Process

A gerontology specialist can provide critical information on age-related impairments, and the most common symptoms among older patients. Accordingly, the gerontology specialist can also perform comprehensive assessments to ensure the healthcare team and caregivers understand the health and medical needs and facilitate the effective transition for the elderly persons (Threapleton et al, 2017).

The gerontology specialist also develops transition care plans by gathering all the relevant patient information and developing the appropriate instructions that should be followed after discharge. The gerontology specialist then shares the transition care plan with members of the multidisciplinary team, the patient and caregivers to ensure a seamless transition (Baldonado et al, 2017). The gerontology specialist plays an active role in the implementation of the care plan and promoting self-management skills for the elderly facilitates communication between the elderly patient/family caregivers and the relevant healthcare providers. The gerontology specialist also promotes medication adherence through active consultation with pharmacists and provided medication education to the patient/caregiver, and by ensuring the efficacy of the medication management system (Patel et al, 2015).  Transitional Care (TC) Project Essay Example

Conclusion

The aging population is faced with multiple chronic conditions, age-related health problems, as well as the issue regarding the management of complex medications. Accordingly, they experience care transition often, and therefore this highlights the significance of good care transition to ensure improved health outcomes. From the video, strategies that can ensure successful care transition include efficient collaboration between primary care providers, patients, and caregivers; provision of a supportive environment to patients and caregivers during and after transition; comprehensive discharge process; and linking patients and care providers with the community resources after discharge. The interview focused on continuity and transition, policy and governance, multi-disciplinary team, communication, patients’ case management, as well as discharge planning and needs assessment for care, and the relevant barriers and facilitators to effective care transition. Finally, the role of the gerontology specialist includes patient assessment and development of personalized transition care plans.

References

Baillie L, Gallini A, Corser R, Gina E et al. (2014). Care transitions for frail, older people from acute hospital wards within an integrated healthcare system in England: a qualitative case study. Int J Integr Care. 14(9).

Baldonado A, Hawk O, Thomas O & Nelson D. (2017).Transitional care management in the outpatient setting. BMJ Qual Improv Rep. 6(1): u212974.w5206.

Hirschman K & Hodgson N. (2018). Evidence-Based Interventions for Transitions in Care for Individuals Living With Dementia. The Gerontologist. 58(1), S129–S140.

Luxford K, Gelb D & Tom D. (2017).Promoting patient-centered care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. International Journal for Quality in Health Care. 23(5), 510–515.

Patel R, Barna B, Danielle C & Eckert L. (2015). Exploring Transitional Care: Evidence-Based Strategies for Improving Provider Communication and Reducing Readmissions. P T. 40(10): 690–694.

Storm M, Siemsen IMD, Laugaland KA, Dyrstad D & Aase K. (2014). Quality in transitional care of the elderly: Key challenges and relevant improvement measures. International Journal of Integrated Care. 14(2).

Threapleton D, Chung R, Wong S, Chau P, Chung E, Jean W. (2017). Integrated care for older populations and its implementation facilitators and barriers: A rapid scoping review. International Journal for Quality in Health Care. 29(3), 327–333.  Transitional Care (TC) Project Essay Example