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Challenges in Transitional Care

Challenges in Transitional Care

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Brief Literature Review

The provision of quality transitional care is significant to all patients since it helps to ascertain that the care needs of the patients are fulfilled once they transition across different care settings. According to McDonagh& Kelly (2010), challenges associated with transitional care result in adverse negative outcomes such as higher healthcare costs, unnecessary hospital readmission rates, reduced life quality and satisfaction levels of the patient as well as increased burden on the caregivers. Coleman and Berenson (2004) note that hospital readmission rates have increased by 37% especially among elderly patients with stroke conditions. Coleman and Berenson (2004) further add that the problem is projected to worsen with the expected population increase of older adults. A number of studies have established that adverse events take place within transitional care and that elderly patients with complex care needs tend to be at higher risks. Additionally, Allen et. al. (2014) maintains that at least 49% of patients experience at least one instance of distance-related medical errors or adverse events during the transitional care period. Some of these events have been reported to be preventable and that their severity could be reduced through the use of earlier corrective actions as they are often brought up by issues like diagnostic test follow-up errors, falls, infections and drug mix-ups(Toles et. al., 2016). The severity of these events may result in permanent disability or in some cases death. At least 50% of the patients experiencing such adverse conditions end up requiring extra health-care services hence increased hospital readmission rates. LaMantia et. al., (2010) notes that the existence of such transitional care problems are brought about by ineffective and poor communication and inconsistencies in the exchange of patient information among the health care providers. In overall, therefore, the literature proposes that there is need to conduct additional research on transitional care in a bid to increase understanding on how the quality of transitional care, especially for the elderly patients, can be enhanced.

Methodology and Design of the Study

The study on transition care covers the hospital admission of patients all the way to their being discharged to their homes under the care of their caregivers. Hence the methodology of the study will include the participant observation study on the admission and discharge transition process. Such will involve having holding conversations with some of the elderly patients as well as their caregivers in regards to their awareness on the providence of transitional care. The observation method will also include a close analysis of the handling of the patients throughout their admission process until they are discharged. Such will include observing how the nurses receive the patients, their conduct in emergency departments as well as how they take care of the patients when in their medical wards. Additionally, the observation method will also cover information on the mode of interactions, coordination, and dialogue between the patients and the health practitioners’ right from the day of admission all the way to the day the patients are discharged from hospitals.

Sampling Methodology

To recruit participants in the study, the sampling method was used. Also, different municipalities were consulted and different nursing leaders were selected using the sampling method, to take part in the interviews hence enhancing the research process. The interviews helped to shed light on the role played by the nursing leaders in the transitional care process for older patients. Hence the interviews were used to collect data and also to dictate the key areas that the nurse leaders should address, as a means to ascertain any existing challenges in transitional care. The interviews were structured in a manner that starts with the general information on transitional care, then on the transition process and lastly on the experiences of the patients during the transition care period. Such will help to collect key information on all aspects of transitional care starting from when the patients are admitted to hospitals all the way to when they are released home and during their recovery period at home.

Necessary Tools

The research process will involve the use of different tools and technologies. The primary consideration, however, is on whether the technology information tools used in the healthcare settings assist to ease the transitional care process. It is critical to note that there exist multiple technologies used in the provision of transitional care among them electronic health records of the patients. These records contain information on the patients and can easily be retrieved to enhance the treatment process.  Also, these records incorporate the clinical decision support which enables the nurses and other key health care personnel to make informed decisions regarding the well-being of the patients. In essence, therefore, health IT experts perform multiple roles with respect to fulfilling transitional care. It is critical to capture all information pertaining to patient needs as it helps to inform the transition care process in addition to the medical history of the patients as well as what needs to be done to help foster their quick recovery. As a result, it is important that the IT health systems are designed in a manner that helps to support the transition process, hence assisting patients to go through the transition process with more ease. Additionally, with the provision of information technology, healthcare professionals can best communicate with the caregivers taking care of the patients hence helping to improve to reduce the instance of hospital readmissions.

Any Algorithms/Flow Maps Created

The main algorithm flow created during the research process is the Fourier Transform. The Fourier transform is regarded as one of the key algorithm methods to be used in healthcare settings (Chen, 2016). Generally, the Fourier transform is a technique used to break down complex signals thus enabling healthcare providers to realize the variations in their activities and to determine the best outcome needs for the patients. Such helps to ensure that the healthcare personnel meet their objectives within the organization and also to confirm whether the patients are fit to be discharged home(Chen, 2016). The second algorithm that will be created is the Mumps algorithm. The Mumps algorithm was recently developed to meet the current patient needs in the medical sector (Baronov &Evan, 2018). Hence, the Mumps algorithm functions as an operating system which helps the health care experts to understand the different aspects of patient needs and to determine on the course of action to be taken (Baronov &Evan, 2018). The Mumps algorithm is currently used in the powering of the all the hospital department hence helping to manage patient clinical records and enabling the healthcare personnel to be fast in assessing the patient health care records thus improving the overall workplace efficiency (Baronov &Evan, 2018). The third algorithm method created is the use of probabilistic data which is a technique that enables for different computer searchers which are deterministic to be carried out. The algorithm technique is very important since it ranks different types of information depending on the likelihood of the patients to adapt well to these methods hence helping to estimate the time that it will take for the patients to remain in hospital (Leyenaar et. al., 2016). Hence the probabilistic data technique is important in the transitional care process as it helps to see that patients remain in hospital long enough until they are fit enough to be absorbed into the home care systems (Leyenaar et. al., 2016). Lastly, medical algorithms are important in aiding the decision-making process hence helping to promote safe healthcare as it eliminates any errors on the part of the healthcare personnel when provided health care services(Chen, 2016).  With the increased cases of medical errors, the medical algorithms come in handy in helping the health care personnel to provide quality health care services and to understand the patient needs hence effectively determining the patients who require specialized care during the transitional care process(Chen, 2016).  Therefore, a medical algorithm in this respect functions as a decision tree which helps to go about complex decisions with the help of programming. In this case, therefore, medical algorithms help to eliminate existing uncertainties in the decision-making process hence improving efficiency in the provision of transitional care


Allen, J., Hutchinson, A. M., Brown, R., & Livingston, P. M. (2014). Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review. BMC health services research, 14(1), 346.

Baronov, D. V. & Evan J. B. (2018).Systems and methods for transitioning patient care from signal based monitoring to risk-based monitoring. U.S. Patent Application 10/062,456, filed August 28, 2018.

Chen, E. T. (2016).Examining the influence of information technology on modern health care.Effective Methods for Modern Healthcare Service Quality and Evaluation (pp. 110-136).IGI Global.

Coleman, E. A., & Berenson, R. A. (2004).Lost in transition: challenges and opportunities for improving the quality of transitional care. Annals of internal medicine, 141(7), 533-536.

LaMantia, M. A., Scheunemann, L. P., Viera, A. J., Busby‐Whitehead, J., & Hanson, L. C. (2010). Interventions to improve transitional care between nursing homes and hospitals: a systematic review. Journal of the American Geriatrics Society, 58(4), 777-782.

Leyenaar, J. K., Desai, A. D., Burkhart, Q., Parast, L., Roth, C. P., McGalliard, J., … &Gidengil, C. A. (2016). Quality measures to assess care transitions for hospitalized children. Pediatrics, 138(2), e20160906.

McDonagh, J. E., & Kelly, D. A. (2010).The challenges and opportunities for transitional care research. Pediatric transplantation, 14(6), 688-700.

Toles, M., Colon-Emeric, C., Asafu-Adjei, J., Moreton, E., & Hanson, L. C. (2016). Transitional care of older adults in skilled nursing facilities: A systematic review. Geriatric Nursing, 37(4), 296-301.

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