Assignment: Transitional Care Plan Essay
Sample Answer for Assignment: Transitional Care Plan Essay Included After Question
Assignment Transitional Care Plan Essay
• Complete an interactive simulation in which you will make decisions about a patient’s end-of-life care. Then, develop a transitional care plan, 4 pages in length, for the patient.
Note: Each assessment in this course builds on your work in the preceding assessment. Therefore complete the assessments in the order in which they are presented.
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 keep patients and their families up-to-date 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.
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:
o Competency 2: Evaluate current factors (such as population health, cost, interprofessional communications) affecting patient outcomes related to care coordination.
Explain the importance of effective communications with other health care and community service agencies involved in the transition.
Identify barriers (actual or potential) to the transfer of accurate patient information from the sending organization to the ultimate patient destination.
o Competency 3: Determine appropriate care coordination performance measures for driving high-quality patient outcomes, based on current accrediting standards and benchmarks.
Explain the importance of each key element of a transitional-care plan.
o Competency 4: Apply relevant evidence-based practices that reflect a shift toward a broader population health focus on patient outcomes.
Provide the key plan elements and information needed to ensure safe, high-quality transitional care and improved patient outcomes.
Develop a strategy for ensuring an accurate provider understanding of the patient medication list, plan of care, and follow-up plan during a patient care transition.
o Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards.
Write clearly and concisely, using correct grammar and mechanics.
Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
Context
Relative to other facets of medical care, research to direct 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.
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Questions to Consider
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.
o What are the likely outcomes of poor care transitions among providers and health care settings?
o Why is effective communication such a vital component of transitional care?
o Where are communication breakdowns likely to occur?
Why?
Have you seen or experienced such breakdowns in your own practice setting?
Resources
Required Resources
The following resources are required to complete your transitional care plan.
o Vila Health: Care Coordination Scenario II | Transcript
Use this multimedia simulation to gather the information you will need to complete your plan.
o APA Style Paper Template [DOCX].
Use this template for your plan.
Suggested Resources
The resources provided here are optional. You may use other resources of your choice to prepare for this assessment; however, you will need to ensure that they are appropriate, credible, and valid. The MSN-FP6610 Introduction to Care Coordination Library Guide can help direct your research, and the Supplemental Resources and Research Resources, both linked from the left navigation menu in your courseroom, provide additional resources to help support you.
Transitions of Care
o Alliance for Home Health Quality and Innovation. (2014). Improving care transitions between hospital and home health: A home health model of care transitions [PDF]. Available from http://ahhqi.org/images/uploads/AHHQI_Care_Transitions_Tools_Kit_r011314.pdf
An ADA-compliant PDF is available here.
o HealthIT.gov National Learning Consortium. (n.d.). Care coordination tool for transition to long-term and post-acute care [PDF]. Retrieved from https://www.healthit.gov/sites/default/files/nlc_ltpac_carecoordinationtool.pdf
o Institute for Clinical Systems Improvement. (2017). Transition communications – Tools and resources. Retrieved from http://www.rarereadmissions.org/areas/transcomm_resources.html
o Institute for Healthcare Improvement. (2012). How-to guide: Improving transitions from the hospital to skilled nursing facilities to reduce avoidable rehospitalizations [PDF]. Retrieved from http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/STAARHowtoGuide_TransitionsSNFsReduceRehospitalizations.pdf
o Joint Commission Center for Transforming Healthcare. (2014). Improving transitions of care: Hand-off communications [PDF]. Available from http://www.centerfortransforminghealthcare.org/assets/4/6/handoff_comm_storyboard.pdf
An analysis of the effects of handoff communications on transitional care.
Find an ADA-compliant PDF here.
o New York State Department of Health. (2008). Suggested model for translational care planning. Retrieved from https://www.health.ny.gov/professionals/patients/discharge_planning/discharge_transition.htm
o Shaver, K. (n.d.). Transitional care management: Better care for our patients [PDF]. Retrieved from http://www.joslin.harvard.edu/Transitional_Care_PP_SUNY_Upstate_show_Oct_7_call.pdf
A presentation of key points about the management of transitional care.
o Transition Care Plan Example [PDF].
Suggested Writing Resources
You are encouraged to explore the following writing resources. You can use them to improve your writing skills and as source materials for seeking answers to specific questions.
o APA Module.
o Academic Honesty & APA Style and Formatting.
o APA Style Paper Tutorial [DOCX].
Capella Resources
o ePortfolio.
• Assessment Instructions
Preparation
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.
To prepare for this assessment, complete the Vila Health: Care Coordination Scenario 2 simulation (linked in the Required Resources) in which 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.
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. A link to an example is provided in the Suggested Resources.
o Format your transitional care plan in APA style; an APA Style Paper Tutorial is also linked in the Suggested Resources to help you. Be sure to include:
A title page and reference page. An abstract is not required.
A running head on all pages.
Appropriate section headings.
o Your plan should be 4 pages in length, not including the title page and references page.
Supporting Evidence
Cite 4–5 sources of scholarly or professional evidence to support your plan.
Developing the Transitional Care Plan
Note: 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.
o 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.
o Explain the importance of each key element of the 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.
o Explain the importance of effective communications with other health care and community services agencies involved in the transition.
Identify potential effects of ineffective communications on patient outcomes and the quality of care.
o Identify barriers (actual or potential) to the transfer of accurate patient information from the sending organization to the ultimate patient destination.
Consider barriers inherent in such care settings as long-term care, sub-acute care, home care services, and home care with support.
Identify at least three barriers.
o Develop a strategy for ensuring that the destination care provider has an accurate understanding of the patient medication list, plan of care, and follow-up plan.
Cite credible evidence to support for your strategy.
o 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.
o Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style.
Portfolio Prompt: You may choose to save your transitional care plan to your ePortfolio.
Lopes Write Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
Important information for writing discussion questions and participation
Welcome to class
Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to
I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.
Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.
If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.
Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.
Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.
I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!
Hi Class,
Please read through the following information on writing a Discussion question response and participation posts.
Contact me if you have any questions.
Important information on Writing a Discussion Question
- Your response needs to be a minimum of 150 words (not including your list of references)
- There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
- Include in-text citations in your response
- Do not include quotes—instead summarize and paraphrase the information
- Follow APA-7th edition
- Points will be deducted if the above is not followed
Participation –replies to your classmates or instructor
- A minimum of 6 responses per week, on at least 3 days of the week.
- Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
- Each response needs to be at least 75 words in length (does not include your list of references)
- Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
- Follow APA 7th edition
- Points will be deducted if the above is not followed
- Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
- Here are some helpful links
- Student paper example
- Citing Sources
- The Writing Center is a great resource