Patient transitions mean transferring patients from one place to another including moving them from homes to hospitals, hospitals to homes, or from healthcare facilities to rehabilitation centers. Transitions help in providing patients with the best care. During transitions, it is critical for health care facilities to ensure that there is an effective interprofessional transfer (Naylor et al., 2017). Our facility promotes interprofessional collaboration by allowing healthcare professionals including doctors, nurses, physicians, and even the subordinate staff to communicate and collaborate to ensure the safety of the patients. During transitions, our nurses have to collaborate with health care professionals of other healthcare centers and hospitals where our patients are shifting to. The collaborative process includes hospitals directors, nurses, physicians, and BSNs. The main goal to reduce the number of rehospitalizations for patients especially those transitioning from acute care settings to home-based care (Britton et al., 2017). Collaboration between healthcare professionals also helps in making the transition process quick and effective.
Nurses have several roles in the patient transition process. Every time a nurse has to transfer a patient, he or she has to accomplish three critical roles including being the voice of the patient, the transition coordinator, and the provider of patient information to other healthcare professionals (Naylor et al., 2017). They also ensure that patients are encouraged as they transition to ensure better health. Nurses also have to support healthy healing practices and develop trust relationships before the transition period. An RN case manager should be able to identify the ongoing needs, hold meetings to identify at-risk patients, and monitor patient’s progress after the transition.
Several gaps in the transition process are related to the quality of health. Among the major gaps include unwillingness of the patients and their family members to collaborate, lack of sufficient information, negligence behavior among team members and delay in transitioning (Britton et al., 2017). Also, quality of care can be affected by patients’ missing records during transition time. improper coordination between healthcare professionals and a lack of sufficient resources to cater to patients’ needs.
References
Naylor, M. D., Shaid, E. C., Carpenter, D., Gass, B., Levine, C., Li, J., … & Williams, M. V. (2017). Components of comprehensive and effective transitional care. Journal of the American Geriatrics Society, 65(6), 1119-1125.
Britton, M. C., Ouellet, G. M., Minges, K. E., Gawel, M., Hodshon, B., & Chaudhry, S. I. (2017). Care transitions between hospitals and skilled nursing facilities: perspectives of sending and receiving providers. The Joint Commission Journal on Quality and Patient Safety, 43(11), 565-572.
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