Transitional Nursing Care Project: Planning Phase

Introduction to the Problem

Transitional nursing care emphasizes the need to pay attention to the process of discharging a patient from a hospital and their transfer to home care. These patients often have multiple comorbidities and have to be consulted by different specialists. Upon discharge, the patients can experience difficulties with health management at home. This paper aims to review the prospect of follow-up calls as a nursing intervention for the improvement of the transitional care model.

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Problem Statement

One issue with transitional care is the ability of patients to navigate through different providers and caregivers as well as settle at home after a hospital visit. The University of Pennsylvania School of Nursing states that adequate management of transition care, especially for elderly patients, is the key to improving outcomes and patient satisfaction (“Transitional care model,” n.d.). Scheduling a phone call to check a patient’s wellbeing can significantly enhance the readmission rates. Hirschman, Shaid, McCauley, Pauly, Naylor (2015) state that many patients experience difficulties when trying to rethink and adjust their lives in accordance with their illness before discharge. This suggests that patients can benefit from additional help in understanding their condition and transitioning to self-management at home.

There are six main issues with transitional care addressing, which can help improve the care continuum for older adults, one of which is follow-up calls facilitated by nurses. Hirschman et al. (2015) argue that “lack of patient engagement; absent or inadequate communication; lack of collaboration among team members; limited follow-up and monitoring; poor continuity of care; and, serious gaps in services as patients move between healthcare professionals (clinicians) and across care settings” (Hirschman et al., 2015, p. ). Hence, the aim of this research is to help the patients, guide them through the process of readjustment, and suggest additional consultations from providers if necessary through follow-up calls.

Significance of the Problem to Nursing

Elderly patients often suffer from multiple chronic conditions that require constant attention from patients. However, as was mentioned, many patients do not fully understand their diagnosis. Upon suffering from an acute episode, they can be treated in the hospital and then discharged home. Rennke and Ranji (2015) argue that improving the monitoring of elderly patients is an essential part of transitional nursing. Since nurses are responsible for caring about their patients, addressing concerns, and guiding them over the course of their treatment, resolving the issue of proper transition management can help patients achieve better health outcomes.

Purpose of the Research

The purpose of the research is to improve the current transitional nursing care by introducing an intervention tailored to the needs of elderly patients. Evidence by Georgiadis and Corrigan (2017) suggests that many elderly patients experience frustration when being discharged from a hospital. Some of them do not feel that they are healthy enough to be discarded, and others report not fully understanding the diagnosis and illness management practices that they should apply while at home. Hence, this project can fill the gap in training by helping patients improve their understanding of the condition they have upon hospital-home transition. Additionally, this can address the issue of readmissions that are highlighted by Georgiadis and Corrigan (2017) as a severe risk factor. Hospitals can benefit from improving the transition care practice since less spending will be necessary for managing readmissions, and patient satisfaction scores should improve as well. During these calls, a patient can receive brief consultations and recommendations for lifestyle adjustments that will be used to adjust his or her management strategies. Additionally, patients can be referred to a specialist if they experience symptoms that require additional attention.

Research Questions

The primary research questions are – do follow-up calls help reduce patient readmissions? Can developing a protocol of scheduled follow-up calls reduce complications? Do follow-up calls improve patient satisfaction? Can follow-up calls reduce instances of complications? Can follow-up calls help patients in transitioning from a healthcare setting to a home environment? More specifically, can these calls improve the patient’s confidence regarding managing their health and help them settle? By answering these questions, nurses will be able to tailor the practice of working transitional care of elderly patients to improve their health outcomes.

Master’s Essentials

This research project is connected to the Master’s Essentials since this paper aims to develop a strategy for improving the quality of care and lead the change in transitional nursing employing the understanding of research design. Additionally, follow-up calls will help enhance the collaboration between different teams, which is essential for adequately managing transitional care. Finally, by using evidence from studies such as patient feedback review by Georgiadis and Corrigan (2017) and implementation of practice improvement, this project aligns with the essentials of translating evidence into nursing practice and designing innovative approaches that can be applied in a real-life healthcare setting.

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Overall, this paper provided evidence suggesting that the follow-up practices of transitional care should be improved. This should result in a better quality of care and reduction of readmission rates, as well as patient complications. This project aims to address the issue of communication and follow-up monitoring. The hypothesis is that elderly patients who were discharged from a hospital after an acute episode can benefit from a regularly scheduled phone call facilitated by a nurse.


Georgiadis, A., & Corrigan, O. (2017). The experience of transitional care for non-medically complex older adults and their family caregivers. Global Qualitative Nursing Research, 4, 1-9. Web.

Hirschman, K., Shaid, E., McCauley, K., Pauly, M., & Naylor, M. (2015). Continuity of care: The transitional care model. OJIN: The Online Journal of Issues in Nursing, 20(3), 1. Web.

Rennke, S., & Ranji, S. R. (2015). Transitional care strategies from hospital to home: a review for the neurohospitalist. The Neurohospitalist, 5(1), 35–42. Web.

Transitional care model. (n.d.). Web.

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StudyCorgi. (2021) 'Transitional Nursing Care Project: Planning Phase'. 19 July.

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