Transition of Care in Nursing

Running head: NURSING
NURSING
Name of the Student:
Name of the University:
Author Note:

1
NURSING
Transition of care
Introduction
Discharge planning can be defined as an interdisciplinary process towards a
continuity of care that involves a set of the steps like the identification, goal setting, planning,
implementation, coordination and the evaluation of the care provided. It can also be defined
as the critical link provided between hospital and the post discharge care provided by the
community (Brown 2018). A proper discharge planningin the transition of care can be helpful
in reducing the length of the hospital stay and also reduces the hospital readmission rates
leading to a reduced health care costs (Verhaeghet al. 2014).
The aim of this report is to discuss about the course of action that has to be taken for the
transition of care from the hospital to home or rehabilitation care centre. The legal and the
ethical issues involved in the transition of care, will be discussed in this paper. While
planning of Joseph’s discharge, the cultural aspect of the patient will also be considered.
Course of action for the discharge procedure
Transfer of care principles
The core principles of transfer of care are person and family centred care, evidence based
quality services, equity in access to care, a strength based approach, strong linkages and
coordination across different sectors and a multidisciplinary approach (Primary health 2016).
A proper setting of the goal is necessary before the commencement of the discharge
planning. Before the initiation of the discharge procedure, a comprehensive evaluation of the
health condition is necessary that would possibly lay out the physical, psychological, short
term and the long term condition of the patient, in order to provide a person centred care

2
NURSING
(Hunter and Birmingham 2013). If any problems persist then the matter can be escalated to
the physicians in charge of the discharge planning. An evidence based approach is required in
providing care to Joseph as it permits the use of maximum level of evidence to provide a
patient centred care. The evidence based approach also facilitates treating patients with
dignity and respect.
According to the transfer of care principle, an interdisciplinary approach is required.
The discharge planning is manly done by an aged care assessment team (ACAT) or a
discharge planning team that contains of a discharge nurse, the physician in charge, a case
manager, a dietician, a nutritionist, and an occupational therapist. The ACAT team assess the
physical, social and spiritual and the cultural needs of the patient (Hunter and Birmingham
2013). The discharge nurses documents the needs of the clients and escalates the matter to the
multidisciplinary team members and are also responsible for recommending suitable referral
to for the clients. The multidisciplinary team conveys health care benefits to both the clients
and the health care members (Hegarty et al. 2014). The MDT that will be required for Joseph
are a discharge nurse, a physician, an occupational therapist, a podiatrist and a social worker.
A discharge nurse would conduct the necessary assessment of the patient’s health condition
before issuing the discharge certificate. An occupational therapist is required for Joseph to
assist him in coping up with the daily activities of living.
Health assessment of Joseph would include a respiratory assessment and a respiratory
assessment for ruling out the chances of brain injury (Hunter and Birmingham 2013). It
should be mentioned that the main clinical priorities for Joseph’s discharge plan is-
hypotension, episodes of delirium due to brain damage occurred due to carbon-monoxide
poisoning. As per the case study Joseph had also displayed symptoms of central line
associated Blood stream infection (CLABSI). At the time of the discharge, Joseph has also
been spotted with a pressure injury at his right heel and hence before the discharge, all these

3
NURSING
conditions in Joseph have to be resolved. The Since Joseph had developed a pressure injury it
is necessary to educate him about the self-care of the wounds and the ways of dressing. A
proper planning for the follow up after discharge is required in case of Joseph. In a study by
Pedersenet al. (2016) it has been found that a proper follow up reduces the rate of hospital
readmissions and the subsequent health care costs.
Home care services
It is evident from the case study that Emma is a single mother of a son, who struggles
with ASD, so it will become very difficult for Emma to balance between her work and her
household duties. Joseph and Emma can be referred to several community care services who
can provide home care support to Joseph. Some of the community care services provide
home care support to the people in lieu of a particular amount of money (Shepperd et al.
2014). Joseph stays in Artarmon, Sydney and a large number of aged care services are there
that can provide support to these patients by liaising and advocating in understanding the
Medicare plans, the incurred cost for the home medical equipment. Calvary Community
care, is a local non-profit home care provider that provides a quality aged and disability home
care services. Home instead senior care in Artarmon, provides high level of care and can
provide assistance in cleaning and drying, food preparation, personal hygiene, dressing,
medication, personal care and allied health care benefits.
Again, at the time of the discharge, the discharge nurse had spotted a pressure injury
on Joseph’s left heel, that might require a follow up care and frequent dressing till it subsides,
thus requiring the assistance of a community nurse. Furthermore, an occupational therapist
should be able to visit Joseph’s place in order to suggest for home environment modification
or to help the patient cope up with the ADLs. A liaison officer might liaise Joseph and his
family regarding the Medicare services that can be availed.