Introduction and Identification of the Problem
The transitional nursing or transitional care model is focused on various types of patients, including chronically ill, elderly, adolescent, and other vulnerable individuals. The model focuses on preventing readmissions and repeated hospitalizations; it also provides patients with detailed instructions and follow-ups that evaluate their quality of life and ability to cope with post-discharge difficulties.
Elderly and frail patients are at increased risk of complications and poor outcomes during their transition from hospital to home (Watkins, Hall, & Kring, 2012). These transitions can be complicated by disrupted communication, inadequate patient and/or caregiver education, and poor access to needed services (Watkins et al., 2012). Specific transitional care models are developed for elderly patients that consider their health status and any chronic conditions or other diseases they have (e.g. dementia, Alzheimer’s disease, diabetes, etc.). Readmissions that had occurred after the discharge of older adults led to $15 billion in costs to Medicare (Watkins et al., 2012).
Some of the programs also engaged a social worker whose role was to coordinate the transition and provide different services that could help the patient cope with their everyday life successfully, such as shopping, laundry, light housekeeping, etc. (Watkins et al., 2012). If the services were not available after discharge, they could lead to poor or negative outcomes of it and even result in additional injuries or traumas in elderly patients. Some of them could go through multiple transitions during a single year. The causes of such repeated transitions and readmissions are still discussed; however, inefficient training of nursing professionals and patient education might be the key reasons behind these repeating transitions.
Significance of the Problem
This problem is significant to nursing because the transitional care model is nursing-led; the nurse is responsible for post-discharge follow-ups, any plans for patient self-care, and contacts with patients. The transitional care model aims to decrease the chance of readmissions, and nurses responsible for patient care during the transition are interested in making it as efficient and cost-effective as possible. According to Callahan et al. (2012), “each transition presents a new risk for miscommunication, duplication of services, medical errors” and conflict of interest with patient or family (p. 815). Additional research will help nurses understand what interventions and changes can contribute to the safe transition of elderly patients.
It is possible to assume that transitional care models are not as efficient as one would anticipate due to the lack of professionals with necessary skills related to transitional nursing, as well as patient’s misunderstanding of instructions or guidelines. Therefore, nursing professionals engaged in transitional nursing need to understand how the lack of specialized skills influences the transition of older patients and whether communication defines the success of the transition.
Purpose of the Research
The purpose of the research is to understand whether the transitional care model is effective with older and frail adults, how it affects the readmission rates of elderly adults, and whether any additional interventions can make it more effective. The research aims to investigate various cases in transitional nursing that will include patients with chronic conditions, mental illnesses, acute strokes, heart failures, and other conditions that can adversely influence their quality of life. Watkins et al. (2012) point out that some of the existing transitional models lack coordination, as well as provision of post-discharge services that focus on the daily living of patients. The limitations of the transitional care model will also be assessed and discussed in this research.
Research Questions
Research questions of the study will mostly focus on the efficiency of transitional care, the impact of additional interventions, and its limitations.
RQ 1: Is the transitional care model effective for transitions and postdischarge life of elderly patients with chronic or other conditions?
RQ 2: Can any additional interventions and activities make the model more effective?
RQ 3: Does the lack of specialized skills in nursing professionals adversely influence the transition of older patients?
RQ 4: What are the limitations of the transitional care model with regard to elderly patients?
Master’s Essentials
The research will align with many Master’s Essentials. For example, Essential IV states that nurses need to translate scholarship into practice; the results of this research will help me understand how the transitional care of older patients can be improved in practice (AACN, 2011). It also addresses the Essential VII, which stresses the importance of interprofessional collaboration between nurses and other healthcare professionals in improving patient health outcomes (AACN, 2011). As a member of a team or collaboration, I will be able to provide the results of this research as evidence of interventions or practices that can make transitional care more effective.
The Essential VIII demonstrates that master’s prepared nurses can integrate different concepts “of evidence-based clinical prevention and population care and services to individuals, families,” and other agents to improve their health (AACN, 2011, p. 5). The research will address the actions necessary for the prevention of admissions and readmissions of elderly adults, as well as other services that can improve their health and quality of life. Thus, the research aligns with several Master’s Essentials and can significantly improve my practice.
References
AACN. (2011). The essentials of Master’s education in nursing.
Callahan, C. M., Arling, G., Tu, W., Rosenman, M. B., Counsell, S. R., Stump, T. E., & Hendrie, H. C. (2012). Transitions in care for older adults with and without dementia. Journal of the American Geriatrics Society, 60(5), 813-820.
Watkins, L., Hall, C., & Kring, D. (2012). Hospital to home: A transition program for frail older adults. Professional Case Management, 17(3), 117-123.