Assignment (5–6 pages, not including title and reference page):
Write a paper in which you address the following:
Identity your selected example of a transition of care.
WRITERS CURRENT APPROVED TRANSITION OF CARE IS – Focusing on transition from hospital to nursing home/rehab
Area of focus is improving family involvement and communication in the transition of care from hospital to skilled nursing facility rather than only communicating with and notifying the patient.
Describe the key stakeholders that might be involved in this transition of care and the leadership strategies you would use to engage and influence them.
Explain how you, as a nurse leader along with your healthcare team, would apply systems thinking when providing a transition of care aligned with the IHI Quadruple Aim framework in order to improve it. Explain the fourth aim and strategy you would use and why.
Explain how systems thinking would inform your improvement plan for the specific transition of care you selected.
Five references to use include –
Allen, J., Hutchinson, A., Brown, R., & Livingston, P. (2018). User Experience and Care for Older People Transitioning from Hospital to Home: Patients’ and Carers’ Perspectives. Health Expectations, 21(2), 518–527. https://doi.org/10.1111/hex.12646
Gitlin, L. N., & Wolff, J. (2012). Family involvement in care transitions of older adults: What do we know and where do we go from here? Annual Review of Gerontology and Geriatrics, 31(1), 31-64. https://doi.org/10.1891/0198-8794.31.31
Jeffs, L., Law, M., Straus, S., Cardoso, R., Lyons, R., & Bell, C. (2013). Defining Quality Outcomes for Complex-Care Patients Transitioning Across the Continuum Using a Structured Panel Process. BMJ Quality & Safety, 22(12), 1014–.
Samal, L., Dykes, P., Greenberg, J., Hasan, O., Venkatesh, A., Volk, L., & Bates, D. (2016). Care Coordination Gaps Due to Lack of Interoperability in The United States: A Qualitative Study and Literature Review. BMC Health Services Research, 16(1). https://doi.org/10.1186/s12913-016-1373-y
Setter, S., Corbett, C., Neumiller, J., Gates, B., Sclar, D., & Sonnett, T. (2009). Effectiveness of A Pharmacist–Nurse Intervention On Resolving Medication Discrepancies for Patients Transitioning from Hospital to Home Health Care. American Journal of Health-System Pharmacy, 66(22), 2027–2031. https://doi.org/10.2146/ajhp080582
Witt, S., Hoyt, J., Witt, S., & Hoyt, J. (2020). Nursing Homes Vs Home Care | What’s the Difference & How to Choose. SeniorLiving.org. Retrieved 24 September 2020, from https://www.seniorliving.org/compare/nursing-home-vs-home-care/