I have attached the part I-Module 2 assignment which I completed. The following assignment must use the references which are in part I that I have attached. To prepare: Review feedback on your Module 2 Assignment 1 (from Week 4). You should incorporate your Instructor’s feedback and continue to add to and refine your annotated bibliography for your selected transition of care. Consider the nurse leader’s role in achieving the IHI Quadruple Aim for this transition of care. (Hint: Draw from resources on systems thinking and nurse leaders’ ability to influence innovation and change.) 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. 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. Be sure your paper includes a title page and a reference page. You should also resubmit your refined Annotated Bibliography. -The response clearly and accurately identifies a transition of care. -The response clearly, accurately, and with appropriate detail describes key stakeholders who may be involved in the transition of care. Leadership strategies for engaging and influencing stakeholders are appropriate, clear, and thoroughly described. -The response accurately and thoroughly explains in detail how to apply systems thinking when providing a transition of care aligned with the IHI Quadruple Aim framework in order to improve it. The fourth aim and strategy are appropriate, clear, and justified. -The response accurately and thoroughly explains how systems thinking would inform the improvement plan for the transition of care.
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Annotated Bibliography on Transition of Care
from Hospitals to Skilled Nursing Facilities
NURS 6201 Section 3
Leadership in Nursing and Healthcare
March 20, 2020
There are many factors toward improving the quality of care for chronically ill older
adults, enhancing transitions within acute hospital settings, and improving patient handoffs to
and from acute care hospitals. The research indicates that there are existing gaps in care for
these patients and their caregivers during critical transitions that can lead to adverse events,
unmet needs, low satisfaction with care, and high rehospitalization rates (Naylor & Keating,
2008). Studies also show that there are key elements to improving these transitions of care and
enhancing the support of family caregivers which are to remain focused on the patients’ and
family caregivers’ needs, preferences, and goals, to utilize interdisciplinary teams guided by
evidence-based protocols, to improve communication among patients, caregivers, and providers,
and to use information systems to monitor care and outcomes (Naylor & Keating, 2008). The
research suggests that comprehensive assessments of patients’ and caregivers’ needs should be
performed at the time of the patients’ admissions to the hospital, since they often lack the
knowledge, skills, and resources to properly manage their follow-on home health care (Naylor &
Keating, 2008). The following annotated bibliography summarizes five scholarly articles that
address different components in the transition of care that nurse leaders must focus on to safely
manage patients’ continuity of care from acute care hospitals to skilled nursing facilities (SNFs).
Dizon, M., Zaltsmann, R., & Reinking, C. (2017). Partnerships in Transitions: Acute Care to
Skilled Nursing Facility. Professional Case Management, 22(4), 163–173. Retrieved
The purpose of this collaborative study was to describe the efforts and results of the work
done to address the need to identify patients at high risk for unplanned readmission to hospitals
after being discharged to skilled nursing (SNFs). According to the study, in 2004, 34% of
Medicare patients were readmitted to the hospital within 90 days of discharge, which resulted in
an estimated cost of $17.4, and older adults discharged to SNFs have higher rates of unplanned
readmissions due to their multiple comorbidities and complex inpatient care. Therefore, Dizon,
Zaltsmann, & Reinking conducted a comprehensive review to identify the unmet needs of
patients and caregivers that could ensure smooth transitions, educate patients and caregivers, and
facilitate communication between acute care facilities and SNFs.
The leadership teams of an acute care hospital in Northern California and eleven SNFs
worked together to focus on collaboration, communication, and competency by identifying
problem areas, objectives to address them, and actions necessary to achieve their established
goals. They conducted monthly meetings to review unplanned readmissions that were evaluated
by the hospital’s NP and SNF clinical staff to identify trends and action items. These reviews
helped to identify gaps in care and opportunities for improvement.
Two case studies were also presented in the article that identified the major problem that
the hospital was not consistent in providing correct information to the SNFs which resulted in the
formulation of three objectives of the hospital-SNF partnership: the creation of standardized
forms for transferring patients, including checklists for hospital to SNF and SNF to ED transfers,
incorporating transitions work in the role of NPs to communicate directly with the bedside nurse
with follow-up calls post transfers, and enhanced communication by video conferencing. The
case studies also identified that end-of-life and palliative care was not adequately addressed by
either agency which led to more thorough assessments of patients’ and caregivers’ needs and
more collaborative communication with consistent messaging regarding end of life care options.
The multidisciplinary work between the hospital and contributing SNFs resulted in
shared accountability, better communication based on teambuilding, enabled smooth transitions,
and improved patient care. It involved bed-side staff and executive support with shared
decision-making among facilities to improve workflow and communication between care
settings. The study also identified future work that can be done, such as including provider to
provider handoffs, collaboration with home health agencies, and the use of standardized
protocols at SNFs to improve patient care while decreasing healthcare costs.
Hirschman, K., Shaid, E., McCauley, K., Pauly, M., & Naylor, M. (2015). Continuity of
Care: The Transitional Care Model. Online Journal Of Issues In Nursing, 20(3), 1.
Retrieved from https://eds-b-ebscohost-com.ezp.waldenulibrary.org/eds/detail/detail?
This article by Hirschman, Shaid, McCauley, and Naylor presents the Transitional Care
Model (TCM), which is an evidence-based, a nurse-led intervention focused on older adults at
risk for poor outcomes as they transfer between healthcare settings and attending providers. The
TCM focuses on the Triple Aim, improving care, enhancing outcomes for patients and family
caregivers, and reducing healthcare costs for chronically ill, older adults. Randomized clinical
trials have demonstrated the success of the TCM to improve acutely ill patients’ experiences,
health, and quality of life outcomes with reduced rehospitalization rates and overall healthcare
costs of the chronically ill.
The authors summarize the model’s core components, which are screening, staffing,
maintaining relationships, engaging patients and family caregivers, assessing and managing risks
and symptoms, educating and promoting self-management, collaborating, promoting continuity,
and fostering coordination which are interconnected and part of a holistic care process. The
staffing used in the TCM uses APRNs who are leading the care for their patients transitioning
from acute hospital care and have been identified as high risk for poor outcomes. The APRNs
maintain the responsibility for the daily delivery of transitional care services as well as
overseeing other healthcare team members. They screen patients, conduct comprehensive
assessments, establish trusted relationships with patients and caregivers, educating them and
promoting self-management to keep them engaged in their healthcare plans. The APRNs also
lead the way, promoting communication and connections between hospital, post-acute, and
community-based staff to facilitate the transfer of essential information using secure email
systems and electronic health records. The APRNs engaged with patients, caregivers, and other
team members work to ensure that patients have smooth transitions of care with comprehensive
The research team established metrics to benchmark adherence and measure the
program’s outcomes. There is an ongoing study to help identify how health systems in America
are adapting the TCM’s core components to improve continuity of care through transitions. The
article states that, according to the Coalition for Evidence Based Policy, the TCM (2014) has
been recognized as a “top-tiered, evidence-based approach” that could have a significant positive
effect on Medicare beneficiaries transitioning from hospital to home. By adopting one or more
of the TCM’s core components to local practices, nurse leaders can implement this care
management approach to improve outcomes and assure that patients and their caregivers have
the support and resources needed to help manage their care.
Jusela, C., Struble, L., Gallagher, N. A., Redman, R., & Ziemba, A. (2017). Communication
Between Acute Care Hospitals and Skilled Nursing Facilities During Care Transitions.
Journal of Gerontological Nursing, 43(3), 19–28. Retrieved from https://doi-org.ezp.
The findings of the research conducted by Jusela, Struble, Gallagher, Redman, and
Ziemba also support the need for improved TCMs and better communication of information
between acute care settings and SNFs for transitioning patients. The article cited an Institute for
Healthcare Improvement’s study from 2014 that reported poor communication of medical
information accounts for nearly 50% of errors during care transitions. These transitions have
been identified as “vulnerable exchange points,” and care plans from one setting are often not
communicated to the next care team.
The study was a retrospective convenience sample chart audit, and all patients admitted
to the SNF from an acute care hospital were examined. The checklist was based on local and
national standards. It revealed the following discrepancies: transferring physician contact
information was missing in 65%, medication lists were missing from 1%, steroid tapering
instructions missing from 42%, antiarrhythmic instructions missing from 38%,
duration/indication of anticoagulant medications missing from 25%, and antibiotic medications
missing from 22% of the patient charts. The accuracy and completeness of the discharging
providers’ instructions also affect patients’ transitions.
There were multiple implications based on the results of this study. The data suggests the
need for education and training of HCPs in both SNF and acute care settings, including
developing standardized forms, designating leadership roles for accountability, and conducting
quality improvement projects. The researchers also suggested cross-continuum team meetings
and the creation of policies and procedures that allow for monitoring and collecting feedback
about discharge planning processes, including information transfer, clinical outcomes, patient
satisfaction, patient understanding, and input from the provider and/or next care setting.
Jusela, Struble, Gallagher, Redman, and Ziemba identified nurse leaders as positioned to
identify recommended elements of data transfer for optimal patient outcomes and capable of
making recommendations for policy reform and quality improvement projects, removing barriers
to care. They suggest the creation of additional educational workshops that would create
awareness of institutional capabilities and/or barriers and would also facilitate smoother
transitions in care. Healthcare providers must be able to communicate effectively and provide
patients and caregivers with the resources that will enable them to be engaged in their care plans.
King, B. J., Gilmore-Bykovskyi, A. L., Roiland, R. A., Polnaszek, B. E., Bowers, B. J., & Kind,
A. J. H. (2013). The consequences of poor communication during transitions from
hospital to skilled nursing facility: a qualitative study. Journal Of The American
Geriatrics Society, 61(7), 1095–1102. Retrieved from: https://doi-org.ezp.waldenu
According to King et al., there are multiple inadequacies of hospital discharge
information, including regular problems with medication orders, little psychosocial or functional
history, and inaccurate information regarding the current health status of patients when patients
are transferring to SNFs. These inadequacies create delays in care, increased SNF staff stress,
frustrated patients and family members, and increased risk of rehospitalization. With all the
deficiencies identified in hospital‐to‐SNF transitions, poor discharge communication was listed
as the primary barrier to safe and effective transitions.
The article reports more than five million patients transition from hospitals to SNFs every
year, and nurses are primarily responsible for receiving and initiating these individuals’ care.
The objective of this study was to examine the patients’ transitions of care, the barriers nurses
experience, and the outcomes associated with variations in the quality of transitions by analyzing
detailed information obtained in focus groups and interviews with practicing SNF nurses. The
research suggests that high‐quality, complete discharge communication is crucial to safe and
effective hospital–SNF transitions, and a lack of transitional care training among health
professionals might contribute to poor‐quality discharge communication since accreditation
guidelines for physician and nursing training programs are vague.
Kerstenetzky, L., Birschbach, M. J., Beach, K. F., Hager, D. R., & Kennelty, K. A. (2018).
Improving medication information transfer between hospitals, skilled-nursing facilities,
and long-term-care pharmacies for hospital discharge transitions of care: A targeted
needs assessment using the Intervention Mapping framework. Research In Social &
Administrative Pharmacy: RSAP, 14(2), 138–145. Retrieved from https://wwwsciencedirect-com.ezp.waldenulibrary.org/science/article/pii/S155174111630374
A patients’ transition from a hospital to a SNF introduces the likelihood of medication
errors. According to this study, three-fourths of hospital to SNF admissions had at least one
medication discrepancy, and approximately 40% of medication errors are thought to be a result
of inadequate medication reconciliation procedures during transitions, with 20% of these errors
are believed to cause patient harm. This study reports on the development of a logic model used
to explore methods for minimizing patient medication delays and errors while further improving
handoff communication from hospital to SNF pharmacy staff to improve the quality of care for
patients transitioning from hospital to SNF.
Communication handoff for patients discharging to SNFs is an interdisciplinary effort
between providers, nurses, pharmacists, and social workers/case managers, but this process is not
standardized across disciplines. The study identified a common theme among SNF staff of onedirectional discharge communication from the hospital with little opportunity for feedback on
patient care concerns. It was also determined that certain communications are expected to occur
as typical workflow, while some only occur if clarifications are necessary. It was determined that
the handoff process for hospital discharge teams should be formalized, and the admitting SNF
will receive handoff education about the contents of the hospital discharge packet to eliminate
gaps in transitional care.
This annotated bibliography summarized five scholarly articles that address different
components in the transition of care that nurse leaders must focus on to safely manage patients’
continuity of care from acute care hospitals to skilled nursing facilities (SNFs). The studies
identified key elements in improving these transitions of care and enhancing the support of
family caregivers. Since multidisciplinary teams are involved when transferring patient care,
each member of the health care team must communicate clearly with each other, patients, and
their family members to comprehensively manage care transitions to reduce healthcare costs,
improve outcomes, and meet the needs of patients and their caregivers.
Naylor, M., & Keating, S. A. (2008). Transitional Care. AJN American Journal of Nursing,
108(9), 58–63. Retrieved from https://doi-org.ezp.waldenulibrary.org/10.1097/
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