Question

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Module 7 Virtual Experience: Case Management - Transitions of Care: Primary Care Clinic Which of the following are possible results of ineffective transitions of care? (Select all that apply.) a) Fewer lab/diagnostic tests b) Increased severity of complications c) Decreased burden on healthcare providers d) Increased readmission e) Lower cost

Answer 1

Transition in care is the transfer of a patient from one unit or another in the same location, or from one healthcare setting to another of different location according to the patient's needs. Transitions provide the development of various strategies and impact patient outcomes. For example, a patient visited primary healthcare physicians for treatment and if his conditions worsen then his transition is to hospital's ICU, and then to the inpatient department where he receives nursing care of different units and then return home. Ineffective transition leads to adverse events. When a patient is not effectively treated and there is an increase in complications in one setting the transition occurs. For example, when a patient received care from a primary setting and the condition worsens, he was transferred to a hospital. When there are increased readmission and increased complications all these are a result of the ineffective transition of care. Hence, the correct answers are option (b) and (c).

Smoking is a serious health problem and various measures have been taken for prevention and cessation of smoking, like advertising, educational programs, interviews and banning in public places. In this case, the nurse knows that her client is moving towards a positive change, and when the client says that he uses nicotine gum when he is around other people who smoke is a good way to keeping himself away from smoking. And having 1 cigarette a day or signing up for any classes will not help him quit smoking. Hence, the correct answer is an option (b). The ANA standard of professional performance included some activities for nursing care. These are quality of practice, education, professional practice evaluation, collegiality, collaboration, ethics, research, resource utilization and leadership. The nurse identifies the clinical problems, uses research pieces of evidence in practice and developing policies and procedures and participates in a unit or organization and helps in data collection. In this case, the nurse is collecting data for the past 6 months and is playing the role of a researcher. Hence, the correct answer is an option (b).

The joint commissions in 2013 given 7 foundations for effective and safe transitions from one hospital/healthcare setting to another are: a) Leadership support b) Multidisciplinary collaboration c) Early identification of patients/clients at risk d) Transitional planning e) Medical management f) Patient and family action/engagement and g) Transfer of information. Weekly appointments and face to face communication are part of the patient care and interprofessional collaboration is about understanding the patient's problems health issues and having team goals and can be able to understand milestones and training of other disciplines. Whereas, multidisciplinary is to understand treatment and assessment by other disciplines. Hence, the correct options are (b) and (e).