CNA345 Professional Practice 4: A Case Study on Transition of Care

This case study presents a comprehensive analysis of Joseph Russo's transition of care, addressing the complexities arising from carbon monoxide poisoning, foot ulcer, and other health concerns. The paper emphasizes the importance of a multidisciplinary approach, involving discharge nurses, physicians, occupational therapists, and social workers, to ensure a smooth transition from hospital to home or rehabilitation center. It highlights the significance of home care services, mental health support for both Joseph and his family, and adherence to legal and ethical principles, particularly respecting patient autonomy and confidentiality. The study also underscores the need for a strength-based approach to care, focusing on Joseph's capabilities and support systems, as well as culturally sensitive care that acknowledges his Italian background and limited English proficiency. Ultimately, the care plan aims to facilitate Joseph's recovery, promote his well-being, and enable him to cope effectively with his health challenges while respecting his cultural identity and preferences.

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Name of the Student:
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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

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(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

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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.

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Mental health services
There are several reasons for Joseph’s and Emma’s anxiety. One, because his son misused his
business and whose whereabouts are not known to them, and second is about Sophia, who
lack functionality and do not have anybody to rely on except Joseph.
The responsibilities of the caregivers should also be determined to provide a
psychosocial support to Joseph and his family. A Psychiatrist or a mental health counsellor
can be appointed who can provide emotional support to both Joseph and Emma as both of
them had been through physical and emotional turmoil.
Legal and the ethical principles
While considering the geriatric clients, the ethical principles should go beyond a clinical
assessment and should also consider the basic rights of the humans. According to the Nursing
and Midwifery Board of Australia (NMBA) standard, the nurses are accountable to preserve
the rights of the patients and abide by the ethical codes of conduct (NMBA 2013). The two
important ethical obligations for the nurses are Beneficence and Non-maleficence that
includes doing well to the patient or avoiding any activities that can harm the patient
(Burkhardt and Nathaniel 2013). Another ethical principle that are found to be breached in
most the elderly cases is the right to make decisions or autonomy. The case study reveals that
Joseph and Sophia does not want to visit a residential care setting. Hence it is necessary to
respect their decision and provide a home care support that would allow them to spend the
last few years of their life in their own house.
Geriatric patients are often vulnerable to confidentiality breach (Burkhardt and Nathaniel
2013). While appointing a home care support, it should be made sure that all only necessary
information about Joseph and Sophia should be provided to the home carer. Exchange of

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health care information should only take place between the family members and the
physician in charge of Joseph.
Strength based approach to care:
In this case Joseph Russo had been suffered an instance of carbon monoxide
poisoning which in turn resulted in him becoming unconscious and being rushed to the health
care facility. The patient suffered a foot ulcer in his left leg as well, for which he requires
extensive and adequate care planning and implementation. In this case, the aid of strength
based care approaches can be taken which in turn can help in the nurses identifying the
capacity, skills, knowledge and values of the patient and integrating the principles into the
care planning and implementation procedures (MacDonald et al. 2018). Focussing on the
strengths of the patient and their family members help in connecting the potentiality of the
individual factors and how it impacts the different individuals while they cope with impact of
the disease that they are suffering with. It has to be mentioned in this context that strength
based approach focuses entirely on strengths of the patient and the support that the patient
might attain from the family. Although, strength based approach is associated with very
limited evidence base and as a result synthesizing evidence based practice is difficult to be
implemented. However, the strength based approach has very high applicability in the care
scenario and as a result, the patient had to deal with caring for his extremely ill wife and the
impact of the disease and his foot ulcer would impair his activity tolerance, in turn affecting
his physical, social and psychological health. Hence, strength based nursing care is a very
important element to be incorporated so that Joseph can successfully he can successfully cope
with his conditions (Doherty 2016).

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Culturally safe care in the development of a plan of action:
From the case study, it can be revealed that as he made only a few friends in the
Italian community after relocating to the Australia, it can be considered that he belongs to a
culturally diverse community, probably Italian. Along with that, the case study also reveals
that he has very limited and reduced English language proficiency, which can also lead to
care planning difficulties and complications when addressing the care needs or progressing
with the discharge planning. In this case, the nurses addressing the discharge planning will
need to take a culturally safe and sensitive nursing care approach so that the cultural and
traditional customs and requirements of the background that Joseph belonged to is respected
at all times (Hole et al. 2015). Similarly, it has to be mentioned that Joseph had very limited
English language proficiency, and as a result, there is also need for language assistance and
interpreters in both care planning and health promotional activities. Similarly, care is needed
to be taken to ensure that his dignity, cultural identity, uniqueness, and rights are addressed
and respected at all circumstances (Brown 2018). Similarly, care is needed to be taken to
ensure that the nurse incorporates any traditional healing concepts and principles into the care
planning and implementation of the care practices so that Joseph Russo gets all his care needs
addressed, attains speedy recovery, and can help him cope with his conditions effectively.
Conclusion:
On a concluding note, it has to be mentioned in this context that the case study of
Joseph Russo represented many care complications which could have adversely affected the
condition that the patient had been in. This essay has successfully identified the various
factors that had direct association with recovery or coping with life. The detailed care plan
with referral services and emphasis on strength based care and cultural safety in care planning
will help the patient attain recovery faster.

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References:
Brown, M.M., 2018. Transitions of Care. In Chronic Illness Care (pp. 369-373). Springer,
Cham.
Burkhardt, M.A. and Nathaniel, A., 2013. Ethics and issues in contemporary nursing. Nelson
Education.
calvarycare.org.au 2016. Calvary Community Care. Access date: 23.1.2019. Retrieved
from:https://www.calvarycare.org.au/community-care/
Doherty, L.M., 2016. Working with children in adolescents in residential care: a strength-
based approach, by B. Bertolino: New York, NY, Taylor and Francis Group, 2015, 177 pp.,
49.95(paperback), 133.64 (hardcover).
Hegarty, C., Buckley, C., Forrest, R. and Marshall, B., 2016. Discharge Planning: Screening
Older Patients for Multidisciplinary Team Referral. International journal of integrated
care, 16(4).
Hole, R.D., Evans, M., Berg, L.D., Bottorff, J.L., Dingwall, C., Alexis, C., Nyberg, J. and
Smith, M.L., 2015. Visibility and voice: Aboriginal people experience culturally safe and
unsafe health care. Qualitative health research, 25(12), pp.1662-1674.
Homeinstead.com.au .2016. Home instead senior care .Access date: 23.1.2019. Retrieved
from: https://lowernorthshore.homeinstead.com.au/
Hunter, T. and Birmingham, J., 2013. Preventing readmissions through comprehensive
discharge planning. Professional case management, 18(2), pp.56-63.

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MacDonald, C., Benc, R., Buono, A.T., Champagne, L., Chartier, G., Cooke, A., Drummond,
N., Gartshore, K., Ehrler, A. and Gottlieb, L., 2018. Strength based nursing: caring for the
whole person. International Journal of Whole Person Care, 5(1).
Nursing and Midwifery Board of Australia (NMBA) 2013, Scope of practice for registered
nurses and midwives, NMBA, Melbourne, May 2013, Access date: 17 January 2018,
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Pedersen, L.H., Gregersen, M., Barat, I. and Damsgaard, E.M., 2016. Early geriatric follow-
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Retrieved from:https://www.primaryhealthtas.com.au/wp-content/uploads/2018/06/
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Shepperd, S., Lannin, N.A., Clemson, L.M., McCluskey, A., Cameron, I.D. and Barras, S.L.,
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Appendix
Name Location Services Estimated cost
Home Instead Senior
care
Sydney Lower North
Shore
Suite 4, Level 1, 57
Grosvenor Street
Neutral Bay New
South Wales 2089
Provides personal
care, domestic and
personal support,
assistive
technologies and
transport
$7645.45
Calvary Community
Care
Level 12, 135 King
Street, Sydney NSW
2000
Residential care,
rehabilitation care
centre, allied
health care, GP
support, cooking
and shopping
support.
$8170.90