The Course of Action for Transfer of Care

Transfer of Care 1
Transfer of Care
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Transfer of Care 2
Transfer of care
Introduction
Transfer of care refers to the process of coordinating continuity of healthcare for the
patient from one healthcare setting for example hospital setting to another care setting, for
example, home-based care according to the needs and changes of the patient. The purpose of this
paper is to explain the goals and course of action for transfer of care according to Joseph ́s case.
Secondly, there will be explanation of care core principles and how they are incorporated in
strengths-based nursing. Third, the paper will describe established goals and comprehensive
course of action for Joseph and his family care requirements. Lastly, there will be explanation of
legal and ethical principles to decision making and cultural safe care in the development of plan
of action.
Goals and Course of Action of Transfer of Care
The purpose of transfer of care is to take the patient into environment where he or she can
resume self-care as he recovers from a health condition. It aims at coaching the patient to be able
to manage their own health information and medications, allowing the patient to understand
signs and symptoms of a disease or a condition. Joseph condition needs proper interventions are
required to reduce his condition of delirium which is characterized by illusions and restlessness
due to his disturbed state of mind (Buijck 2018, p.221).
According to Joseph condition, transfer of care from hospital management to home
management can be designed for at least 30 days after discharge. The intervention target to have
him receive medical support from his family members especially his daughter Emma to manage
and understand complex postdischarge needs. People around him have to ensure that there is

Transfer of Care 3
continuity of care to help reduce risks of physical and emotional stress for both caregivers and
the patient (Wright 2013, pp.225).
Transfer of Care Core Principles
Nurses are required to help facilitate discharge of patients to help them develop strength
that can promote quick recovery and facilitate healing. Strengths-Based Nursing Care (SBNC)
requires good leadership from nurses to incorporate strength based nursing principles and
transfer of care core principle. The following are the transfer of care core principles which
should be observed before discharge is made (Aziz et al. 2013, p.413).
1. Care is centered on the patient and their family. According to this principle,
family members who are caregivers for the patient during home-based care have to collaborate
effectively with healthcare professions in order to receive services that place the patient at the
center of their healthcare.
2. Evidence-based quality services. Healthcare professionals and caregivers have to
work together to ensure there is shared decision making during patient care at home.
3. Equity in access to care. The principle states that the patient should easily have
access to support services according to his or her needs. In the case of Joseph, he may need
constant reassurance to reduce the risks of stress.
4. Strengths-based approach. This approach is intended to identify what the patient
is able to do and helping them to achieve their desired goals.
5. Strong coordination and linkages across sectors. The principle requires
caregivers and healthcare professionals to work together in an integrated and coordinated
approach to ensure quality services are delivered to the patient and considering communication
as a key.