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End of Life plan

Develop a transitional care plan

INTRODUCTION

To help reduce care fragmentation, a care coordinator working with patients who suffer from chronic illnesses must share important clinical information with stakeholders so everyone has clear shared expectations about their roles. Equally important, the care coordinator must work with the team to provide updated information to patients and their families and to ensure that effective transitions and referrals take place. This assessment provides an opportunity for you to assume the role of care coordinator and recommend appropriate transitional care for a terminally ill patient.

Relative to other facets of medical care, research directing efforts to improve care coordination has lacked rigor. However, many groundbreaking health care organizations have acknowledged the perils of poorly coordinated care models and applied interventions to improve these models. The objective of care coordination is to secure high-quality recommendations and transitions that aim for superior health care and guarantee that all involved providers, organizations, and patients have the necessary information and resources to make optimal patient care possible.

PREPARATION

As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment.

• What are the likely outcomes of poor care transitions among providers and health care settings?
• Why is effective communication such a vital component of transitional care?
• Where are communication breakdowns likely to occur?
  • Why?
  • Have you seen or experienced such breakdowns in your own practice setting?

In the previous assessment, you conducted simulated stakeholder interviews and collected information for a plan of care for Mrs. Snyder. Now, seven months later, her condition has deteriorated.(Will post a summary of MRS SNYDER )

To prepare for this assessment, complete the following simulation:—————————–

In this simulation, you will recommend appropriate end-of-life care for Mrs. Snyder and see how those recommendations can affect the lives of the patient and her family. Completing this exercise will help you develop a transitional care plan for Mrs. Snyder.

Note:Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

REQUIREMENTS

Develop a transitional care plan for Mrs. Snyder.

Transitional Care Plan Format and Length

You may use a familiar transitional care plan format or template—for example, one used in your organization—or you may create your own.

• Format your transitional care plan in APA style; . Be sure to include:
  • A title page and references page. An abstract is not required.
  • A running head on all pages.
  • Appropriate section headings.
• Your plan should be 4–5 pages in length, not including the title page and references page.

Supporting Evidence

Cite 3–5 sources of scholarly or professional evidence to support your plan.

Developing the Transitional Care Plan

The requirements outlined below correspond to the grading criteria in the scoring guide. Be sure that your transitional care plan addresses each point, at a minimum. Read the Transitional Care Plan Scoring Guide to better understand how each criterion will be assessed.

• Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.
  • Include elements such as emergency and advance directive information, medication reconciliation, plan of care, and available community and health care resources.
• Explain the importance of each key element of a transitional care plan.
  • Identify potential effects of incomplete or inaccurate information on patient outcomes and the quality of care.
  • Cite credible evidence to support your assessment of each element’s importance.
• Explain the importance of effective communications with other health care and community services agencies.
  • Identify potential effects of ineffective communications on patient outcomes and the quality of care during the transition.
• Identify barriers to the transfer of accurate patient information from the sending organization to the patient destination.
  • Consider barriers (actual or potential) inherent in such care settings as long-term care, subacute care, home care services, and home care with support, family involvement, et cetera.
  • Identify at least three barriers (actual or potential).
• Develop a strategy for ensuring that the destination care provider has an accurate understanding of continued care.
  • Consider the patient medication list, plan of care, or other aspects of the follow-up plan or discharge instructions.
  • Cite credible evidence to support your strategy.
• Write clearly and concisely, using correct grammar and mechanics.
  • Express your main points and conclusions coherently.
  • Proofread your writing to minimize errors that could distract readers and make it difficult to focus on the substance of your plan.
• Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.

Competencies Measured/Scoring Guide

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

• Competency 1: Develop patient assessments.
  • Assess a patient’s condition from a coordinated-care perspective.
  • Develop nursing diagnoses that align with patient assessment data.
• Competency 3: Evaluate care coordination plans and outcomes according to performance measures and professional standards.
  • Evaluate care coordination outcomes according to measures and standards.
• Competency 4: Develop collaborative interventions that address the needs of diverse populations and varied settings.
  • Determine appropriate nursing or collaborative interventions.
  • Explain why each intervention is indicated or therapeutic.
• Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards. 

Scenario/ Challenge Details

Rebecca Snyder, 56, is the matriarch of a traditional Orthodox Jewish family. She is the mother of five, including two teenagers at home, and the grandmother of seven. She was brought into the emergency room with uncontrolled diabetes and hyperglycemia. The doctors discovered other problems, and unfortunately Mrs. Snyder was diagnosed with advanced ovarian cancer.she is the primary caregiver in her family, she and her family are especially ill-prepared for this serious diagnosis. You will be responsible for investigating this situation and for helping Mrs. Snyder and her family get the care and support they need.