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Please respond to your peer’s posts, from an FNP perspective. To ensure that your responses are substantive, use at least two of these prompts:

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  • Do you agree with your peers’ assessment?
  • Take an opposing view to a peer and present a logical argument supporting an alternate opinion.
  • Share your thoughts on how you support their opinion and explain why.
  • Present new references that support your opinions.

Please be sure to validate your opinions and ideas with citations and references in APA format. Substantive means that you add something new to the discussion, you aren’t just agreeing. This is also a time to ask questions or offer information surrounding the topic addressed by your peers. Personal experience is appropriate for a substantive discussion and should be correlated to the literature.Be sure to review your APA errors in your reference list, specifically you have capitalization errors in some words of the titles.Include the DOI. Also, be sure you are italicizing titles of online sources.No more than 200 words maximum.

These are the questions my peers had to answer:

The American Geriatrics Society (2003) defines transitional care as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location” (Cited in Boltz, et. al., 2012). It also encompasses both the sending and the receiving aspects of the transfer and is based on a comprehensive plan of care and includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition” (Coleman & Boult, 2003 cited in Boltz, et. al., 2012). Finally, it involves a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings” (Naylor & Keating, 2008 cited in Boltz, et. al., 2012). Therefore, transitional care is an essential component of managing very ill geriatric clients. You will be expected to provide this care.

  • Select five research articles that address transitional care of the geriatric client and briefly describe at least three strategies you will use in your practice to minimize the negative effects associated with transitional care.

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Latara’s Response:

Transitional care encompasses a broad range of services and environments designed to promote the safe and timely passage of patients between levels of health care and across care settings. High-quality transitional care is especially important for older adults with multiple chronic conditions and complex therapeutic regimens, as well as for their family caregivers. These patients typically receive care from many providers and move frequently within health care settings. A growing body of evidence suggests that they are particularly vulnerable to breakdowns in care and thus have the greatest need for transitional care services (Brown, & Bub, 2016). Poor “handoff” of these older adults and their family caregivers from hospital to home has been linked to adverse events, low satisfaction with care, and high re-hospitalization rates.

Many factors contribute to gaps in care during critical transitions. Poor communication, incomplete transfer of information, inadequate education of older adults and their family caregivers, limited access to essential services, and the absence of a single point person to ensure continuity of care all contribute (Farhat, Vordenberg, Marshall, Suh, & Remington, (2019). Language and health literacy issues and cultural differences exacerbate the problem. To prevent the above it would be beneficial to ensure we engage patients (and families) as partners in planning and managing their care and that we utilize effective educational strategies, including teach-back and other methods of assessing understanding, with instructions written at the patient’s health literacy level. In the primary care setting, reconciliation of the patient’s medications immediately after discharge from a hospital and ensure a timely follow-up visit in the primary care office is helpful. Also making sure durable medical equipment, follow-up testing, and home care have been scheduled and received (Peel, Kah Wai Chan, & Hubbard, 2015). Finally, work with patients and families to mitigate preventable factors

Optimal management of care transitions includes patient and family education, coordination and arrangement of care in the post-acute care setting, and aiding communication among healthcare professionals involved in the patient’s care transition(North, 2016). Transitional care interventions have shown success in preventing recurring and avoidable readmissions of chronically ill or at-risk adults after a hospital discharge by utilizing home visits, encouraging timely visits to healthcare providers, promoting chronic-disease self-management, and encouraging more collaboration between disciplines (Gupta, Perry, & Kozar, 2019). Interventions often include well-trained healthcare providers educating patients and their families on how to identify common problems that may arise during and following transitions in care.

Brown, H. L., & Bub, L. (2016). Care transitions across the continuum: Improving geriatric competence. Geriatric Nursing37(1), 68–70. https://doi.org/10.1016/j.gerinurse.2015.12.005

Farhat, N. M., Vordenberg, S. E., Marshall, V. D., Suh, T. T., & Remington, T. L. (2019). Evaluation of Interdisciplinary Geriatric Transitions of Care on Readmission Rates. American Journal of Managed Care25(7), e219–e223. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=137681856&site=ehost-live (Links to an external site.)

Gupta, S., Perry, J. A., & Kozar, R. (2019). Transitions of Care in Geriatric Medicine. Clinics in Geriatric Medicine35(1), 45–52. https://doi.org/10.1016/j.cger.2018.08.005 (Links to an external site.)

North, C. (2016). Comprehensive geriatric assessment of a mental health service user with safeguarding needs. Nursing Older People28(5), 25–29. https://doi.org/10.7748/nop.28.5.25.s25

Peel, N. M., Kah Wai Chan, & Hubbard, R. E. (2015). Outcomes of cognitively impaired older people in Transition Care. Australasian Journal on Ageing34(1), 53–57. https://doi.org/10.1111/ajag.12168

Gerald’s Response:

Select five research articles that address transitional care of the geriatric client and briefly describe at least three strategies you will use in your practice to minimize the negative effects associated with transitional care.

Transitional of care is defined as the movement of a patient from one setting of care to another (“Agency for Healthcare Research and Quality,” 2018) This care is essential among the elderly with complex regimens and their caregivers. These settings include hospitals, ambulatory care facilities, home health agencies, and nursing homes. The main goal of this model is to ensure quality services are delivered. Quality is defined in six dimensions; safe and avoiding harm, effective and follows best practices, patient-centered, timely, equitability, and affordability (“Agency for Healthcare Research and Quality,” 2018). The vital component in the delivery of transitional care is communication among the involved health care providers. Another critical element is the handover of the patient and patient’s information. Several challenges limit the delivery of transitional care. They include poor communication, lack of integration in the plan for care, health care incompetency, and interfered information exchange (Smith et al., 2015). Therefore, there are interventions to curb these challenges.

It is always vital to involve the next of kin in the care of the patient to enhance continuity and quality care delivery. This will include organizing meetings with the next-of-kin, sharing information with him, and planning for follow-up care. Research also recognizes the role of the family in providing the patient’s needs and prevent adverse events from happening (Hirschman, Shaid, McCauley, Pauly, & Naylor, 2015). There is a need to prepare the kin psychologically and physically to avoid cases of stress due to pressure from responsibility. This involves giving them the needed information, engaging them in care planning meetings, and encouraging them to prolong participation in admission and discharge.

Addressing the patient’s characteristics will be another strategy that will help in minimizing the negative effects associated with the transitional of care. This includes preparation of the patient for all events such as delay during admission, preparing for discharge, and providing the patient with information regarding the disease (Storm, Siemsen, Laugaland, Dyrstad, & Aase, 2014). This supports their plans for life after discharge before the day arrives. Patients with immobility are less likely to be involved in the planning of care. However, patient-centered transitional care requires that the patient and the next of kin be involved in the plan of care, as well as be prepared for discharge and how to manage the condition at home.

Communication is a key determinant in the success and quality of transitional care. Activities that enhance delivery and exchange of information include delivering timely reports, written hand over information and using web-based transfer of key information (Levin, Peterson, Dolansky, & Boxer, 2014). These activities also include standardizing routines and procedures of patient’s transition to minimize on cost and time used in delivery of information needed.


Agency for Healthcare Research and Quality. (2018). Six domains of healthcare quality Retrieved December 10, 2019, from https://www.ahrq.gov/talkingquality/measures/six-d…

Hirschman, K., Shaid, E., McCauley, K., Pauly, M., & Naylor, M. (2015). Continuity of care: The transitional care model. Retrieved December 10, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/26882510

Levin, J., Peterson, P., Dolansky, M., & Boxer, R. (2014). Health literacy and heart failure management in patient-caregiver dyads. Retrieved December 10, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/25072623

Smith, S., O’Conor, R., Curtis, L., Waite, K., Deary, I., Paasche, M., & Wolf, M. (2015). Low health literacy predicts decline in physical function among older adults: findings from the LitCog cohort study. Retrieved December 10, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/25573701

Storm, M., Siemsen, I., Laugaland, K., Dyrstad, D., & Aase, K. (2014). Quality in transitional care of the elderly: Key challenges and relevant improvement measures. Retrieved December 10, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/24868196

Agency for Healthcare Research and Quality. (2018). Transition of care. Retrieved December 10, 2019, from https://www.ahrq.gov/research/findings/nhqrdr/char…

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