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Transitional Care Models

Transitional Care Models

Sample Answer 

Transitional Care Models

Transitional Care Models

Since transitional care is associated with several negative effects, there are various strategies I would use to minimize these negative effects. One of these strategies is robust discharge planning. Through robust discharge planning, an individualized plan for a patient can be developed, and this would ensure a patient leaves a health facility at the right time (Foster et al., 2017). This also ensures a smooth transition of care between health facilities, with proper referral arrangements being made (Rezapour-Nasrabad, 2018). A timely patient discharge also ensures that a patient does not suffer from hospital hospital-acquired infections while being transferred from one health facility to another.

I would also ensure effective communication between healthcare providers and patients to minimize the negative effects associated with transitional care. I would implement this by ensuring written instructions and checklists regarding the transition for caregivers, family members, and patients. Written instructions can improve the quality of care the patient is being given in the event he/she is transferred to another facility (Ziebarth & Campbell, 2019). In addition, I would promote communication between healthcare providers by making sure that only agreed standardized terminologies are used in the written instructions. It has been shown that healthcare providers who use terminologies that other health care providers cannot easily understand have led to several patients being readmitted.

There are several post-discharge interventions I would also put in place to ensure a smooth transition from one level of care to another. I would ensure that there is outreach to patients through home visits, patient-activated hotlines, and follow-up phone calls. Health outreach programs are important in providing patient education to caregivers. I would also ensure that there is medication reconciliation after discharge (Michaelsen et al., 2015). Medication reconciliation is important in preventing medication errors. Medication errors avoided through medication reconciliation are drug interactions, omissions, dosing errors, and duplications (Ba et al., 2020).


Ba, H. M., Son, Y. J., Lee, K., & Kim, B. H. (2020). Transitional care interventions for patients with heart failure: An integrative review. International Journal of Environmental Research and Public Health, 17(8), 1–18.

Foster, H. E., Minden, K., Clemente, D., Leon, L., Mcdonagh, J. E., Kamphuis, S., Berggren, K., Pelt, P. Van, Wouters, C., Waite-jones, J., Tattersall, R., Wyllie, R., Stones, S. R., Martini, A., Constantin, T., & Schalm, S. (2017). EULAR / PReS standards and recommendations for the transitional care of young people with juvenile-onset rheumatic diseases. 639–646.

Michaelsen, M., McCague, P., Bradley, C., & Sahm, L. (2015). Medication Reconciliation at Discharge from Hospital: A Systematic Review of the Quantitative Literature. Pharmacy, 3(2), 53–71.

Rezapour-Nasrabad, R. (2018). Transitional care model: Managing the experience of hospital at home. Electronic Journal of General Medicine, 15(5).

Ziebarth, D. J., & Campbell, K. (2019). Describing Transitional Care Using the Nursing Intervention Classification : Faith Community Nursing. International Journal of Faith Community Nursing, 5(1), Article 3.


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Transitional Care Models

NU 627 DT 15 Instructions

Unit 15 Discussion – Transitional Care Models


It is anticipated that the initial discussion response should be in the range of 250-300 words. Response posts must demonstrate topic knowledge and scholarly engagement with peers. This is not the only criteria utilized for evaluation; substantive content is imperative. All questions in the topic must be addressed. Please proofread your response carefully for grammar and spelling. Do not upload any attachments. All responses need to be supported by a minimum of one scholarly resource. Journals and websites must be cited appropriately. Citation and reference must adhere to APA format.

Transitional Care Models

Transitional Care Models

Discussion Prompt 

The American Geriatrics Society (2003) defines transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location” (Cited in Boltz, et. al., 2012). It also encompasses both the sending and the receiving aspects of the transfer and is based on a comprehensive plan of care and includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition” (Coleman & Boult, 2003 cited in Boltz, et. al., 2012). Finally, it involves a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings” (Naylor & Keating, 2008 cited in Boltz, et. al., 2012). Therefore, transitional care is an essential component of managing very ill geriatric clients. You will be expected to provide this care.

  • Select five research articles that address transitional care of the geriatric client and briefly describe at least three strategies you will use in your practice to minimize the negative effects associated with transitional care.

Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with citations and references in APA format.

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