Develop a Transitional Care Plan for Mrs. Snyder

Develop a Transitional Care Plan for Mrs. Snyder

A Transitional Care Plan for Mrs. Snyder: Moving from Fern Hill Center to a Hospice

Within seven months of care for Mrs. Rebecca Snyder, she has had to be moved from home care with the assistance of a home care giver to Fern Hill Center where she could get round-the-clock medical and nursing care. Together with her family, they have been happy with the care she has been receiving from Fern Hill Center. It has been quality care that is holistic; taking care of her physically, emotionally, spiritually, morally, mentally, and socially. The care has also been culturally appropriate and competent. This has been demonstrated by the fact that she could have her dogs brought to her daily, as well as have her traditional and religious kosher foods. Despite this, however, the fact is that she is terminally ill with ovarian cancer and her condition was bound to deteriorate finally. The time has now come to transfer her care to a hospice where deteriorating terminally-ill patients are offered expert end-of-life oncology care. This paper is concerned with this transition of care for Mrs. Snyder from Fern Hill Center to the hospice. It recognizes the need for transitional care planning (Herndon et al., 2012) to avoid care fragmentation which can negatively impact Mrs. Snyder’s end-of-life quality of care.Develop a Transitional Care Plan for Mrs. Snyder

Key Transitional Care Plan Elements

The Importance of Each Transitional Care Plan Element

Having an advance directive is extremely important with regard to maintaining the bioethical principle of autonomy and its associated doctrine of informed consent. If Mrs. Snyder goes into a comma, for instance, who will decide that she be taken off life support? Or if she goes into shock, which family member will have the MPOA to give a “do-not-resuscitate” or DNR directive? This respect for autonomy is what this element seeks to address and hence makes it important. Inaccurate or improper handling of this element can have a very negative impact on the family if Mrs. Snyder were to die in circumstances that they were not party to (Fine, 2020; Entwistle, 2019; Karnik & Kanekar, 2016).   Develop a Transitional Care Plan for Mrs. Snyder

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            The importance of medical reconciliation is in the fact that medical errors are bound to occur and cause harm to the patients if that is not done. Incomplete or inaccurate carrying out this element may result in severe adverse drug reactions or even premature death, as stated in the Institute of Medicine (IOM) report To Err Is Human (Palatnik, 2016). The importance of a strategic plan of care is in the fact that it facilitates a better quality of life for the terminally ill and sensitivity to the family. Inaccurate handling of this element may result in depression for family members premature death of the patient (Herndon et al., 2012). Lastly, finding available community and healthcare resources is critical as it helps give the family the much needed psychosocial support. Incorrect handling of this causes anxiety and depression and may result in suicidality among the closest family members (Corey, 2017).

Significance of Effective Communications and Barriers to Transfer of Accurate Patient Information

Communication is the medium through which care providers transfer patient information from one care setting to another. Effective communication is therefore important in that it enables care givers from the Fern Hill Center in this case to pass all the information about Mrs. Snyder to those at the hospice. It must be done in the spirit of interprofessional collaboration. Ineffective communication may therefore result in leaving out some of the medications Mrs. Snyder is getting. If these were pain medications, for instance, she would experience a surge in pain with increased suffering on admission at the hospice.

There are several barriers (potential and actual) that hinder the effective transfer of patient information from the sending organization (Fern Hill Center in this case) to the receiving organization (the hospice). Examples of three barriers are: (1) unplanned or unscheduled transfer of a patient. This is the arbitrary and rushed decision to transfer a patient before even gathering all their care information in one place. The chances of leaving out essential information are great. (2) The lack of designation of a single person responsible for handing over the patient and all her information from the discharging organization to the admitting one. This is an actual barrier reported in practice. (3) The presence of an overwhelming workload to registered nurses who are also the ones responsible for handling the patient’s transition of care from one facility to another. Therefore, even if one RN is designated to handle the transition, they may be overwhelmed since they have to multitask and chances of errors in this scenario are high.

Strategy for Ensuring the Destination Care Provider Has an Accurate Understanding of Continued Care

To ensure the receiving hospice accurately understands Mrs. Snyder’s continued care, the following will happen:

• There will be only one comprehensive medication list compiled with Mrs. Snyder’s medications since she was diagnosed with the ovarian cancer seven months ago.
• The RN tasked with transferring Mrs. Snyder from Fern Hill Center to the hospice will hand over the latest care plan that Mrs. Snyder was on right before discharge. This will facilitate care continuity and will provide a basis on which the oncology nurses will plan their care.
• There will be no disparate discharge instructions. All will be in one place in a single document to avoid confusion and errors (Herndon et al., 2012).Develop a Transitional Care Plan for Mrs. Snyder

Conclusion

Care transition is a critical moment in the management of any patient. If not handled properly and carefully, there will be care fragmentation since the care givers receiving the patient will not have complete information regarding the patient. The result will be unfavorable patient outcomes and a threat to patient safety. This paper has looked at this issue with reference to Mrs. Snyder who is terminally ill with ovarian cancer and requires transfer from Fern Hill Center to a hospice.

References

Corey, G. (2017). Theory and practice of counseling and psychotherapy, 10^th ed. Cengage Learning.

Entwistle, J.W.C. (2019). Noninformed consent and autonomy. The Annals of Thoracic Surgery, 108(6), 1610. https://doi.org/10.1016/j.athoracsur.2019.08.006

Fine, L.E. (February 14, 2020). End of life decisions: Powers of attorney & living wills. https://www.lawpracticetoday.org/article/end-life-decisions-powers-attorney-living-wills/

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. http://public.qualityforum.org/actionregistry/Lists/List%20of%20Actions/Attachments/86/IHI%20How%20To%20Guide-%20Improving%20the%20Transition%20from%20the%20Hospital%20to%20Skilled%20Nursing%20Facilities.pdf

Karnik, S., & Kanekar, A. (2016). Ethical issues surrounding end-of-life care: A narrative review. Healthcare, 4(2), 1-6. https://doi.org/10.3390/healthcare4020024

Palatnik, A. (2016). To err is human. Nursing Critical Care, 11(5), 4. Doi: https://doi.org/10.1097/01.CCN.0000490961.44977.8d

Develop a Transitional Care Plan for Mrs. Snyder