Transfer of Care: Principles, Goals, and Action Plan for Joseph

This report provides a comprehensive overview of transfer of care, focusing on the goals, principles, and actions necessary for a successful transition from hospital to home-based care, specifically in the context of Joseph's case. It emphasizes the importance of strengths-based nursing, collaborative partnerships, and patient self-determination in achieving optimal outcomes. The report also addresses the legal and ethical considerations involved in decision-making, highlighting the need for informed consent, respect for patient autonomy, and cultural sensitivity in developing a comprehensive care plan. The ultimate goal is to ensure continuity of care, reduce risks of stress for both the patient and caregivers, and promote a smooth recovery process.

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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

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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.

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6. Interdisciplinary approach. The principle states that patients who are at the core
of care should receive holistic care (Allen et al. 2014, p.346).
Goals and Comprehensive Course of Action That Considers Joseph Family.
1. Collaborative partnership. Strengths-based nursing leadership principle of
collaborative partnership can be applied to ensure continuous respect for patient, openness, and
power sharing. In the case of Joseph, confidentiality must be observed to ensure there are no
discussions about his condition which he never wanted to discuss. Care should also be extended
to his immediate wife Sophia who is suffering from heart failure and COPD which can
contribute to stress experienced by Joseph.
2. To allow self-determination. The aim of this goal is to allow the patient to do what
he can do best and helping them to maximize their potentials and talents. This approach requires
observation of confidentiality among all parties, for example, Emma the daughter to Joseph and
healthcare providers have to make sure everything that is done is in respect to the patient needs
(van Staa and Sattoe 2014, pp.796).
3. To monitor and evaluate patient while at home. Healthcare professions have to
ensure there is continuous monitoring of Joseph to make sure recovery process is successful and
any other conditions that may come up are handled urgently. Josephś family can be provided
with written information with clear guidance of what they are expected to do to maintain the
patient in stable state while at home. Family members who are taking care of the patient are also
required to report any unusual observations from the patient to the healthcare team for an
effective remedy.

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Legal and Ethical Principles of Decision Making
Decision making is the process of understanding benefits and risks when giving and
receiving medical treatment. There are four components of decision making.
1. Decision making must be voluntarily granted consent which means there should
be no duress or coercion. For example, the process of Joseph discharge should include all parties
and let them understand the care process they need to undertake to keep the patient in stable state
and also make the patient aware of discharge.
2. Medical practitioners have to explain treatment information, procedures, and tests
including risks and benefits to the patient without excluding any information. They have to
explain to family members the importance of taking medication while at home and risks of
skipping or not taking drugs as prescribed.
3. The person making a decision should have the capacity to make consent. In the
case of Joseph, if he is not able to make the right decisions about his health, his daughter who is
taking care of him can take consent on behalf of her dad.
4. Relevant information must also be comprehended. Information about a safe
environment for effective home-based care must be provided to the family. They should also be
informed of warning signs from their patient that they should report immediately they see them
(Burkhardt and Nathaniel 2013).
Cultural Safe Care in Development of The Action Plan
Cultural awareness is essential in ensuring effective healthcare management. It affects
family support, adherence to medication and patient communication. Family members and close
friends to Joseph have to be notified of the condition that Joseph is going through to accept and

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help the family in management. They have to be explained in detail what the condition is and
characteristics of a person of this condition. (Douglas et al. 2014, pp.109).
Conclusion
Transfer of care should be done in collaboration with all parties; the family, patient and
healthcare professionals. Interventions such as self-determination and collaborative awareness
should be promoted to help the patient to maximize his potential during recovery in observation
of care core principles. Cultural safe care should also be promoted to create awareness about the
condition the patient is going through and create understanding about the whole situation
including management care that is needed for easy recovery.

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References
Allen, J., Hutchinson, A.M., Brown, R. and Livingston, P.M., 2014. Quality care outcomes
following transitional care interventions for older people from hospital to home: a
systematic review. BMC health services research, 14(1), p.346.
Aziz, A.F.A., Aziz, N.A.A., Nordin, N.A.M., Ali, M.F., Sulong, S. and Aljunid, S.M., 2013.
What is next after transfer of care from hospital to home for stroke patients? Evaluation
of a community stroke care service based in a primary care clinic. Journal of
neurosciences in rural practice, 4(4), p.413.
Buijck, B. (2018). Integrated care issues: Transfer of patient care information. International
Journal of Integrated Care, 18(s2), p.221.
Burkhardt, M.A. and Nathaniel, A., 2013. Ethics and issues in contemporary nursing. Nelson
Education.
Douglas, M.K., Rosenkoetter, M., Pacquiao, D.F., Callister, L.C., Hattar-Pollara, M.,
Lauderdale, J., Milstead, J., Nardi, D. and Purnell, L., 2014. Guidelines for implementing
culturally competent nursing care. Journal of Transcultural Nursing, 25(2), pp.109-121.
van Staa, A. and Sattoe, J.N., 2014. Young adults' experiences and satisfaction with the transfer
of care. Journal of Adolescent Health, 55(6), pp.796-803.
Wright, S., 2013. Examining transfer of care processes in nurse anesthesia practice: introducing
the PATIENT protocol. American Association of Nurse Anesthetists Journal, 81(3),
pp.225-232.

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