BSN Writing Services

BSN Writing Services

Call Us

+1-(612) 234-7670

Our Email

NURS FPX 6610 Assessment 3 Transitional Care Plan

Student Name

Capella University

NURS-FPX 6610 Introduction to Care Coordination

Prof. Name


Transitional Care Plan


Transitional care plays a crucial role in ensuring the quality of care and safety of patients, particularly during shifts between different phases of treatment. This assessment focuses on developing a transitional care plan for Mrs. Snyder, a 56-year-old patient with diabetes admitted to Villa Hospital due to an infected toe. The plan aims to address her healthcare needs and identify communication barriers that may affect the overall transitional process (Korytkowski et al., 2022).

Key Elements & Information Needed for High-Quality Treatment

Effective patient care relies on precise diagnosis, continuous monitoring, and comprehensive medical records management (Watts et al., 2020). Key elements necessary for Mrs. Snyder’s treatment include:

Medical Records

Collecting Mrs. Snyder’s medical records enables a better understanding of her health status, facilitating accurate diagnosis and treatment of associated conditions (Chen et al., 2018).

Medication Reconciliation

Accurate medication reconciliation ensures appropriate treatment, minimizes errors, and improves patient outcomes (Fernandes et al., 2020).

Emergency and Advance Directive Information

Obtaining advance directive information and understanding Mrs. Snyder’s preferences and religious beliefs are vital for providing patient-centered care and preventing complications (Dowling et al., 2020).

Patient Feedback

Incorporating patient feedback helps healthcare professionals tailor treatment plans to meet individual needs and enhance patient satisfaction (Moghaddam et al., 2019).

Plan of Care and Education

Customized care plans and patient education are essential for empowering patients like Mrs. Snyder to manage their conditions effectively (Dyer, 2021).

Community and Health Care Resources

Access to community resources and support services is critical for preventing adverse outcomes and promoting patient well-being (Yue et al., 2019).

Insightful Assessment of Patient’s Needs

A comprehensive assessment, including medical tests, prescriptions, counseling documents, and social support, is necessary for seamless transitions and optimal care delivery (Humphries et al., 2020).

Importance of Key Elements of a Transitional Care Plan

Each key element contributes to the effectiveness of transitional care plans by addressing patients’ unique needs and ensuring continuity of care (Blackwood et al., 2019).

Potential Effects of Incomplete or Inaccurate Information on Care

Incomplete or inaccurate information can lead to treatment delays, medication errors, and compromised patient safety (Zirpe et al., 2020).

Importance of Effective Communication

Effective communication fosters trust, enhances collaboration, and reduces the risk of adverse events, ultimately improving patient outcomes (Garcia-Jorda et al., 2022).

Potential Effects of Ineffective Communications

Ineffective communication may result in treatment delays, health disparities, increased costs, and diminished patient satisfaction (Raeisi et al., 2019).

Barriers to the Transfer of Accurate Patient Information

Challenges such as staffing shortages, incomplete medical histories, and inadequate training in electronic health records can impede the transfer of accurate patient information (Ilardo & Speciale, 2020; Tsai et al., 2020).

Strategy to Establish Absolute Understanding of Continued Care

Effective strategies include meticulous planning, follow-up sessions, and clear communication to ensure the seamless transfer of information and improve patient outcomes (Glans et al., 2020).


A well-executed transitional care plan is crucial for optimizing patient care during healthcare transitions. By addressing key elements, overcoming communication barriers, and implementing effective strategies, healthcare providers can ensure Mrs. Snyder receives the best possible care and support her in managing her diabetes effectively.


Moghaddam, M. A.A., Zarei, E., Bagherzadeh, R., Dargahi, H., & Farrokhi, P. (2019). Evaluation of service quality from patients’ viewpoint. BMC Health Services Research, 19(1).

Blackwood, D. H., Walker, D., Mythen, M. G., Taylor, R. M., & Vindrola-Padros, C. (2019). Barriers to advance care planning with patients as perceived by nurses and other healthcare professionals: A systematic review. Journal of Clinical Nursing, 28(23-24), 4276–4297.

Borulkar, R., Dhande, P., & Dhande, P. (2022). Medication Reconciliation: A beneficial tool in patient safety 1 1. Bharati Vidyapeeth Medical Journal (BVMJ), 2(3).

Chen, Y., Ding, S., Xu, Z., Zheng, H., & Yang, S. (2018). Blockchain-based medical records secure storage and medical service framework. Journal of Medical Systems, 43(1).

Cullati, S., Bochatay, N., Maître, F., Laroche, T., Muller-Juge, V., Blondon, K. S., Junod Perron, N., Bajwa, N. M., Viet Vu, N., Kim, S., Savoldelli, G. L., Hudelson, P., Chopard, P., & Nendaz, M. R. (2019). When team conflicts threaten the quality of care: A study of health care professionals’ experiences and perceptions. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(1), 43–51.

Dowling, T., Kennedy, S., & Foran, S. (2020). Implementing advance directives—An international literature review of important considerations for nurses. Journal of Nursing Management, 28(6).

Dyer, E. (2021). It’s about people: Caring agents and satisfied patients are key to a successful healthcare call center culture. Management in Healthcare, 6(2), 134–141.

NURS FPX 6610 Assessment 3 Transitional Care Plan

Fernandes, B. D., Almeida, P. H. R. F., Foppa, A. A., Sousa, C. T., Ayres, L. R., & Chemello, C. (2020). Pharmacist-led medication reconciliation at patient discharge: A scoping review. Research in Social and Administrative Pharmacy, 16(5), 605–613.

Fiorillo, A., Barlati, S., Bellomo, A., Corrivetti, G., Nicolò, G., Sampogna, G., Stanga, V., Veltro, F., Maina, G., & Vita, A. (2020). The role of shared decision-making in improving adherence to pharmacological treatments in patients with schizophrenia: a clinical review. Annals of General Psychiatry, 19(1).

Garcia-Jorda, D., Fabreau, G. E., Li, Q. K. W., Polachek, A., Milaney, K., McLane, P., & McBrien, K. A. (2022). Being a member of a novel transitional case management team for patients with unstable housing: an ethnographic study. BMC Health Services Research, 22(1).

Glans, M., Kragh Ekstam, A., Jakobsson, U., Bondesson, Å., & Midlöv, P. (2020). Risk factors for hospital readmission in older adults within 30 days of discharge – A comparative retrospective study. BMC Geriatrics, 20(1).

Humphries, C., Jaganathan, S., Panniyammakal, J., Singh, S., Dorairaj, P., Price, M., Gill, P., Greenfield, S., Lilford, R., & Manaseki-Holland, S. (2020). Investigating discharge communication for chronic disease patients in three hospitals in India. Plos One, 15(4), 0230438.

NURS FPX 6610 Assessment 3 Transitional Care Plan

Ilardo, M. L., & Speciale, A. (2020). The community pharmacist: Perceived barriers and patient-centered care communication. International Journal of Environmental Research and Public Health, 17(2).

Kaper, M. S., Winter, A. F. de, Bevilacqua, R., Giammarchi, C., McCusker, A., Sixsmith, J., Koot, J. A. R., & Reijneveld, S. A. (2019). Positive Outcomes of a Comprehensive Health Literacy Communication training for health professionals in three European countries: A multi-center pre-post intervention study. International Journal of Environmental Research and Public Health, 16(20), 3923.

Korytkowski, M. T., Muniyappa, R., Antinori-Lent, K., Donihi, A. C., Drincic, A. T., Hirsch, I. B., Luger, A., McDonnell, M. E., Murad, M. H., Nielsen, C., Pegg, C., Rushakoff, R. J., Santesso, N., & Umpierrez, G. E. (2022). Management of hyperglycemia in hospitalized adult patients in non-critical care settings: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism.

Raeisi, A., Rarani, M. A., & Soltani, F. (2019). Challenges of the patient handover process in healthcare services: A systematic review. Journal of Education and Health Promotion, 8(173).

Schultz, B. E., Corbett, C. F., Hughes, R. G., & Bell, N. (2021). Scoping review: Social support impacts hospital readmission rates. Journal of Clinical Nursing.

NURS FPX 6610 Assessment 3 Transitional Care Plan

Spencer, R. A., & Singh Punia, H. (2020). A scoping review of communication tools applicable to patients and their primary care providers after discharge from the hospital. Patient Education and Counseling.

Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of electronic health record implementation and barriers to adoption and use: A scoping review and qualitative analysis of the content. Life, 10(12), 327.

Watts, G. F., Gidding, S. S., Mata, P., Pang, J., Sullivan, D. R., Yamashita, S., Raal, F. J., Santos, R. D., & Ray, K. K. (2020). Familial hypercholesterolemia: Evolving knowledge for designing adaptive models of care. Nature Reviews Cardiology, 17(6), 360–377.

Yazdinejad, A., Srivastava, G., Parizi, R. M., Dehghantanha, A., Choo, K.-K. . R., & Aledhari, M. (2020). Decentralized authentication of distributed patients in hospital networks using blockchain. IEEE Journal of Biomedical and Health Informatics, 24(8), 2146–2156.

Yue, D., Pourat, N., Chen, X., Lu, C., Zhou, W., Daniel, M., Hoang, H., Sripipatana, A., & Ponce, N. A. (2019). Enabling services to improve access to care, preventive services, and satisfaction among health center patients. Health Affairs, 38(9), 1468–1474.

Zirpe, K., Seta, B., Gholap, S., Aurangabadi, K., Gurav, S. K., Deshmukh, A. M., Wankhede, P., Suryawanshi, P., Vasanth, S., Kurian, M., Philip, E., Jagtap, N., & Pandit, E. (2020). Incidence of medication error in critical care unit of a tertiary care hospital: Where do we stand? Indian Journal of Critical Care Medicine, 24(9), 799–803.