Patients' and caregivers are vulnerable interchange spots for patients and caregivers that result in increased risk for adverse health outcomes (hospital, other institutions and homes). The Institute of Medicine and National Quality Forum have recognized as a national goal the improvement of transitions from acute care to house. Despite this, health care transitions continue to be inefficient for people with disables, such as stroke, resulting in unexpected demands of the patient and caregiver, higher safety hazards, high rates of unnecessary readmission rates and heightened healthcare expenditures (Camicia & Lutz, 2016). Family caregivers play a very important role in helping older persons during and especially after their hospitalization. But little attention has been paid to the particular requirements of family caregivers during care transitions until recently. Accordingly, caregivers consistently assess their commitment to decision-making regarding discharge arrangements and the quality of preparedness for the next phase of care. The researchers analyzed Medline, CINAHL and Social Work Abstracts databases with combinations of the following terms: research, 65 years of age, continuity in patient care, transfers, medication management and post-discharge in attempt to comprehend the state of scientific knowledge relating to transitional care models for elderly adults and the functions of family caregivers in such models (DelBoccio et al., 2018).
Readmissions from hospital contexts to the community are a widely watched measurement of the efficiency of care transition. Readmissions may suggest persistent issues, inadequate care release, immediate aftercare quality, or a blend of all elements. 6 After the hospital release, thirty-day readmission rate is recorded at 14.4%, of which 11.9% are considered preventable (Camicia & Lutz, 2016). According to the severity of stroke deficiency, readmissions following rehabilitation output range from 9.0% to 16.7%. 8 The most important readmission rate is 30 days for patients released to specialized nursing facilities.
To conclude, literature research suggests that nurses need an extensive awareness of care changes from different levels of care to help patients achieve optimal health outcomes. Transitional care is aimed to encourage a safe and timely mobility of patients through the various healthcare areas. A complete transmission and communication from the ICU to the medical surgeons was essential to this patient's promptness with the complex medical history of Patient S and his recent chest pain episode.
Camicia, M., & Lutz, B. J. (2016). Nursing’s role in successful transitions across settings. Stroke, 47(11), e246-e249.
DelBoccio, S., Smith, D., Hicks, M., Lowe, P., Graves-Rust, J., Volland, J., & Fryda, S. (2018). Successes and challenges in patient care transition programming: one hospital’s journey. OJIN: The Online Journal of Issues in Nursing, 20(3).
Naylor, M. D., & Van Cleave, J. A. N. E. T. (2019). Transitional care model. Transitions theory: middle-range and situation-specific theories in nursing research and practice. New York: Springer Publishing, 459-65.
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