Transfer of Care

Transfer of Care 1
Transfer of Care
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Transfer of care

Transfer of Care 2
Introduction
Transfer of care can be defined as the process of coordinating continuity of healthcare
delivery to patients between different care settings for example between hospital wards or from
hospital to home-based care. Transfer of care is usually done according to changes of patients
health and needs which require a different approach and in a unique environment. Firstly, this
paper will explain course of action and goals of transfer of care according to Joseph ́s case.
Secondly, there will be an explanation of care core principles and how they are incorporated in
strengths-based nursing. Thirdly, the paper will describe established goals and comprehensive
course of action for Joseph and his family care requirements. Lastly, there will be an explanation
of ethical and legal principles of decision making and cultural safe care when developmenting
patient plan of action.
Goals and course of action of transfer or care
The purpose of transfer of care is to move a patient from one healthcare environment to
another healthcare setting which meets optimal conditions and needs of that patient. It involves
taking care and training of the patient to be able to take care of their own health by observing
medication and allowing them to understand signs and symptoms of a disease or condition
affecting (Anhang et al. 2014, pp.522). Considering Joseph condition, the immediate family need
proper management training to be able to understand the behaviors of an affected person
including signs and symptoms of the condition. Awareness about the patient condition is
intended to create a better understanding between patients and his caregivers while at home
(Aebersold and Tschannen 2013, p.2).
A well structure transfer of care action plan for a patient like Joseph should be designed
to cover a duration of 30 days. This is to ensure proper interventions to handle post-discharge

Transfer of Care 3
needs and issues that may be experienced by the patient. During this period, the patient will
receive medical support from his daughter Emma to manage and understand the condition. This
will help to reduce both emotional and physical risks to the patient and caregivers (Braithwaite,
Wears and Hollnagel 2015, pp.418).
Transfer of care core principles
It is a responsibility of nurses to help patients and their family members to develop
strength that can promote quick recovery and facilitate healing after discharge. Nurses are
required to incorporate Strengths-Based Nursing Care and transfer of care core principle when
planning discharge of a patient. Below are the transfer of care core principles that should be
considered before patient discharge is made (Dale, and Hvalvik 2013, p.379).
Evidence-based quality services. There should be a good working relationship between
family caregivers and healthcare providers to help in designing an effective action plan that
meets the patient needs.
Equity in access to care. The environment where the patient is being transferred to should
allow him to have easy access to medical services. Joseph and the family members should be
able to access medical services from local health facilities anytime they need.
Strengths-based approach. This approach focuses on identifying abilities of the patient
after discharge and enabling them to achieve their desired outcomes.
Care is centered on the patient and their family. This principle requires effective
collaboration between caregivers at home and health professionals to ensure patient is at the
center of services and quality services are provided according to discharge guidelines

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Good coordination and linkages across sectors. The principle focuses on ensuring an
integrated approach that is well coordinated to make sure patient basic needs are provided for
example access to medical care from his local community setting.
Interdisciplinary approach. The principle requires healthcare providers and family
caregivers to ensure the patient receives holistic care.
Services That Can be received from Tasmania Community
Since Joseph had just been discharged from the hospital, Tasmania community would
provide the following services to him and the family:
● Helping the family to raise money for their basic needs such as food.
● Coordinating with Emma to help her in providing care to her parents who are all
sick through shift working.
● Provide both social and moral support to the family.
● Helping in the movement of the client from one point to another including when
going to the hospital for medical check-ups.
● Advising the family on best practices and issues involving patient care and
support.
● Helping the family in meeting the patient needs such as purchase of food and
medications.
● Helping the family to ensure patient environment is conducive and meets the
minimum standard requirements for easy recovery.
● Medical check up services from community health nursing team.
● Mental health services can also be provided by community health nursing team.