Effective Transition of Patient Care
In this CPE, you will experience the role of a graduate degree prepared nurse who is a Patient Care Transition Coordinator. For the purpose of this CPE, a Patient Care Transition Coordinator is defined as a nurse who focuses on assisting patients moving from the hospital to a rehabilitation facility, and then to their homes. During this experience, you will help specific patients move through different levels and types of care. You will identify the education, experience, and skills required for you to perform this role successfully. Additionally, as a Patient Care Transition Coordinator, you should aim to prevent hospitalization and rehospitalization of patients who returned to their homes after hospitalization and rehabilitation.In this CPE, you will experience the role of advanced professional nurse in the transitions of care from hospital to home or sub-acute or chronic facility.
The task is comprised of three phases of the transitions of healthcare continuum for a patient. You will examine and discuss evidence-based practices for a selected patient with one of the conditions or procedures identified by the CMS Hospital Readmissions Reduction Program (HRRP). Patient scenarios for each of the conditions or procedures follow the instructions.
The three phases on which you will focus are:
Transition from hospital to home or sub-acute care facility
Discuss the HRRP readmission reduction plan.
Provide introduction to your patient and discuss pre-discharge initiative/interventions to promote optimal recovery and prevent readmission within 30 days or less.
Reduction of all-cause, non-disease-specific readmissions
Research and discuss evidence-based practices for effectively transitioning patient from facility to home with specific focus on preventing all-cause hospital readmissions.
Incorporate social determinants of health considerations that impact all-cause readmissions and how to prevent them with focused interventions or initiatives for your patient targeting the individual, community, and system levels.
Primary, secondary, and tertiary strategies to prevent hospitalization
Research and discuss approaches to impact/reduce hospitalization utilizing primary, secondary, and tertiary prevention initiatives focusing on the individual, community, and system level specific to your patient’s condition or procedure.
Student Instructions:
Type in your name and date at the top of this form
Type in the name of your assigned course instructor
Complete and date the required activities
Submit the completed CPE record for evaluation as a word document or .pdf in the assessment tab for the task.
If you cannot open resources with the web links in this document, open a new browser tab and copy and paste the URL into your browser’s address bar.
PHASE 1: Evidence Based Practices for Effective Transition of Patient Care
Check box when complete
CPE Activity
Date Activity Completed
STEP 1
· Review all the activity and evidence requirements for this CPE for the 3 components of the paper.
· Create a CPE schedule table in your e-portfolio that includes:
o A list of the activities and tasks you need to complete
o Dates of completion for each activity
o Time needed to complete each activity
STEP 2
· Research the CMS HRRP https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
· Briefly discuss the elements and criteria used for the CMS HRRP conditions/procedures payment reduction plan for readmissions within 30 days of discharge.
· Develop/propose a Care Transition Plan for the patient with the condition or procedure that you chose for your CPE.
o Incorporate individual, social determinants, community, system-level, and condition/procedure specific considerations with emphasis on interventions and initiatives to prevent readmission within 30 days of discharge.
PHASE 2: Identifying EBP for the Prevention of Hospital Readmission
STEP 3
· Research the evidence-based practices for effectively transitioning patients from the hospital (& rehabilitation unit) to home with the specific focus on preventing all-cause hospital readmission. Utilize your textbooks, online resources, and other sources as needed.
· Discuss evidence-based practices focused on preventing all-cause hospital readmissions.
· Incorporate individual, community, system, and social determinants of health considerations that impact all-cause readmission and how to prevent them.
PHASE 3: Development of a Hospital Prevention Plan
STEP 4
· Based on research, create an extension of the HRRP that focuses on successfully preventing hospitalization through primary, secondary, and tertiary prevention methods.
· Initiatives should incorporate individual, social, community, system-level, and condition/procedure specific considerations.
STEP 5
· Record and post one 3–5 minute GoReact https://lrps.wgu.edu/provision/303936046
video reflection discussing what you accomplished and learned from each of the components of your transitions of care paper in CPE phase 3.
· Summarize your reflection and paste under a screenshot of your video
· Watch two peers’ videos and provide them encouraging and constructive feedback.
· Take a screenshot of your peers’ videos with your comments and paste them into your document prior to the references.
FINAL STEP
· Copy and paste each of the phase elements into the matching phase tab in your e-portfolio
· Provide a shared link to your e-portfolio
Advanced Health Assessment of Patients and Populations CPE Case Scenarios
Directions:
As the Patient Care Transition Coordinator, you are tasked with effectively transitioning patients home and helping them to avoid readmission to the hospital. Choose one of the following HRRP conditions or procedures patient scenarios and create a comprehensive transition and prevention plan based on the information provided. Review the CPE Record document carefully for directions on completing the comprehensive transition and prevention plan components for Phase 1, 2, and 3 of the Clinical Practice Experience for this course.