NURS-FPX 6610 Introduction to Care Coordination

Transitional Care Plan and Goals of Continuing Care

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In this case presentation, I will explore transitional care within healthcare settings. Transitional care involves catering to patients during transitions between healthcare facilities to safeguard their well-being (Daliri et al., 2019). The paramount objective of hospital staff is to facilitate seamless and manageable transfers for patients. This presentation will discuss the case of Mrs. Snyder, a 56-year-old patient requiring transfer due to her critical condition. The goal of continuing care is to deliver quality treatment to Mrs. Snyder while honoring her religious and cultural beliefs, given her Jewish background, amidst her serious health challenges.

Stakeholder Part in Patient Health and Safety

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Stakeholders play a pivotal role in ensuring the quality of care and safety of patients (Lianov et al., 2020). It is incumbent upon stakeholders to ensure patient cooperation and mitigate undue burdens. In Mrs. Snyder’s case, healthcare professionals must facilitate her transfer between facilities with minimal disruption. Given her Jewish faith, healthcare providers involved in the transfer process must prioritize her cultural and religious considerations. Mrs. Snyder’s preferences, including her dietary requirements for Kosher food, must be diligently addressed to provide comprehensive care (Lianov et al., 2020).

Elements of Continuous Care

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Continuous care encompasses several essential components, including thorough assessment of patient and familial medical records to identify underlying health issues (Pervjakova et al., 2022). Accurate patient evaluation serves as the cornerstone for effective treatment. Additionally, meticulous collection of medical records is crucial for seamless data transmission within healthcare organizations (Asmirajanti et al., 2019).

Patient Assessment

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Mrs. Snyder presents with multiple health concerns necessitating careful consideration of her medical history for transitional treatment planning. Her evaluation reveals critical conditions such as ovarian cancer and diabetes, alongside stress and depression exacerbated by chemotherapy (Khanlarkhani et al., 2021; Demir et al., 2021). Given her cultural and religious beliefs, Mrs. Snyder seeks a healthcare environment that respects her preferences while providing necessary care and support.

Inter-professional Care Team

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Effective patient care requires seamless coordination among various healthcare professionals. Mrs. Snyder’s interdisciplinary care team comprises specialists addressing her diverse medical needs, ensuring adherence to treatment protocols (Ansa et al., 2020). Nurses play a crucial role in facilitating patient referrals, adjusting treatment regimens, and advocating for optimal care settings.

Factors Affecting Patient Outcomes

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Patient outcomes are influenced by diverse factors, including economic status, lifestyle, social support, and environmental conditions (Chung et al., 2020).

Assumption

The assumption underlying Mrs. Snyder’s care is her adherence to Judaism, necessitating consideration of her dietary restrictions. Moreover, her family’s unstable circumstances, compounded by economic stress and familial issues, underscore the importance of ensuring her comfort and support during treatment.

Areas of Uncertainties

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Uncertainty is inevitable in patient care, emphasizing the need for nurses equipped with adequate training to address critical situations effectively (Chung et al., 2020).

Determination of Required Resources

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To ensure effective care for Mrs. Snyder, various resources are indispensable, including regular monitoring of vital signs, adherence to dietary guidelines, and access to necessary medical equipment (Howell et al., 2020).

Conclusion

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Mrs. Snyder’s complex health challenges underscore the importance of tailored transitional care plans. By respecting patients’ religious and cultural beliefs and leveraging multidisciplinary approaches, healthcare providers can enhance patient outcomes and reduce mortality rates. Transitional care is a vital aspect of patient management, necessitating strategic initiatives to address individual needs effectively. As healthcare providers, it is imperative to prioritize patients’ well-being and ensure comprehensi