Phase 1 Infection Prevention Feedback Hello Robert Excellent paper, you provided an in-depth background on the selected topic (Transitional Care). You followed the provided instructions and highlighted the importance of conducting this research as well as the necessity to do it. The purpose of the research was clearly stated, However, for this class select one research question and the question needs to be more specific to specific population. Please make the necessary changes for the final paper. Great job. Thanks, Phase 2 Design Feedback Hello Good description, you provided an excellent description of different articles related to the topic. Your literature review is clear and well organized. You followed the instructions of the assignment and provided a description of the method and sample selection in a clear and transparent way. APA is appropriate. Excellent overall paper. Implementation Phase 3 Feedback Hello Great job highlighting the steps necessary to implement your project. You accentuated, all the different sections, including a timeline as recommended by the assignment instructions. APA is adequate. Thanks Phase 4 Results Hello Good description of the results phase. You provided specific information regarding the results of the project, following the assignment's instructions. There were a new APA errors, in regards to citation format and headings. Thanks. 1. Outstanding 4 points Very Good 3 points Good 2 Points Unacceptable 1 point Integration of Knowledge 12.5% The paper demonstrates that the author fully understands and has applied concepts learned in the course. Concepts are integrated into the writer’s own insights. The writer provides concluding remarks that show analysis and synthesis of ideas The paper demonstrates that the author, for the most part, understands and has applied concepts learned in the course. Some of the conclusions, however, are not supported in the body of the paper The paper demonstrates that the author, to a certain extent, understands and has applied concepts learned in the course The paper does not demonstrate that the author has fully understood and applied concepts learned in the course. Topic Focus 12.5% The topic is focused narrowly enough for the scope of this assignment. A thesis statement provides direction for the paper, either by statement of a position or hypothesis The topic is focused but lacks direction. The paper is about a specific topic but the writer has not established a position. The topic is too broad for the scope of this assignment. The topic is not clearly defined Depth of Discussion 12.5 % In-depth discussion and elaboration in all sections of the paper. In-depth discussion and elaboration in most sections of the paper. The writer has omitted pertinent content. Quotations from others outweigh the writer’s own ideas excessively. Cursory discussion in all the sections of the paper or brief discussion in only ...

1. Phase 1 Infection Prevention
Feedback
Hello Robert Excellent paper, you provided an in-depth
background on the selected topic (Transitional Care). You
followed the provided instructions and highlighted the
importance of conducting this research as well as the necessity
to do it. The purpose of the research was clearly stated,
However, for this class select one research question and the
question needs to be more specific to specific population.
Please make the necessary changes for the final paper. Great
job. Thanks,
Phase 2 Design
Feedback
Hello Good description, you provided an excellent description
of different articles related to the topic. Your literature review
is clear and well organized. You followed the instructions of the
assignment and provided a description of the method and
sample selection in a clear and transparent way. APA is
appropriate. Excellent overall paper.
Implementation Phase 3
Feedback
Hello Great job highlighting the steps necessary to implement
your project. You accentuated, all the different sections,
including a timeline as recommended by the assignment
instructions. APA is adequate. Thanks
Phase 4 Results
Hello Good description of the results phase. You provided
specific information regarding the results of the project,
following the assignment's instructions. There were a new APA
errors, in regards to citation format and headings. Thanks.

2. 1.
Outstanding 4 points
Very Good 3 points
Good 2 Points
Unacceptable 1 point
Integration of Knowledge
12.5%
The paper demonstrates that the author fully understands and
has applied concepts learned in the course.
Concepts are integrated into the writer’s own insights.
The writer provides concluding remarks that show analysis and
synthesis of ideas
The paper demonstrates that the author, for the most part,
understands and has applied concepts learned in the course.
Some of the conclusions, however, are not supported in the
body of the paper
The paper demonstrates that the author, to a certain extent,
understands and has applied concepts learned in the course
The paper does not demonstrate that the author has fully
understood and applied concepts learned in the course.
Topic Focus
12.5%
The topic is focused narrowly enough for the scope of this
assignment.
A thesis statement provides direction for the paper, either by
statement of a position or hypothesis
The topic is focused but lacks direction.
The paper is about a specific topic but the writer has not
established a position.
The topic is too broad for the scope of this assignment.
The topic is not clearly defined
Depth of Discussion
12.5 %
In-depth discussion and elaboration in all sections of the paper.

3. In-depth discussion and elaboration in most sections of the
paper.
The writer has omitted pertinent content.
Quotations from others outweigh the writer’s own ideas
excessively.
Cursory discussion in all the sections of the paper or brief
discussion in only a few sections
Cohesiveness
12.5%
Ties together information from all sources.
Paper flows from one issue to the next without the need for
headings.
Author’s writing demonstrates an understanding of the
relationship among material obtained from all sources
For the most part, ties together information from all sources.
Paper flows with only some disjointedness.
Author’s writing demonstrates an understanding of the
relationship among material obtained from all sources.
Sometimes ties together information from all sources.
Paper does not flow.
Disjointedness is apparent.
Author’s writing does not demonstrate an understanding of the
relationship among material obtained from all sources.
Does not tie together information.
Paper does not flow and appears to be created from disparate
issues.
Headings are necessary to link concepts.
Writing does not demonstrate understanding any relationship
Spelling and Grammar 12.5%
Minimal spelling and/or grammar mistakes
Some spelling and or grammar mistakes.
Noticeable spelling and grammar mistakes.
Unacceptable number of spelling and/or grammar mistakes
Sources
12.5%
More than 5 current sources, of which at least 3 are peer review

4. journal articles or scholarly books.
Sources include both general background sources and
specialized sources.
Special-interest sources and popular literature and
acknowledged as such if they are cited.
All web sites utilized are authoritative.
5 current sources, of which at least 2 are peer-review journal
articles or scholarly books.
All web sites utilized are authoritative.
Fewer than 5 current sources or fewer than 2 of 5 are peer-
reviewed journal articles or scholarly books. All web sites
utilized are credible.
Fewer than 5 current sources or fewer than 2 of 5 are peer-
reviewed journal articles or scholarly books. Not all web sites
utilized are credible, and/or sources are not current.
Citations
12.5%
Cites all data obtained from other sources.
APA citation style is used in both text and bibliography
Cites most data obtained from other sources.
APA citation style is used in both text and bibliography.
Cites some data obtained from other sources.
Citation style is either inconsistent or incorrect.
Does not cite sources.
Running Head: CHALLENGES IN TRANSITIONAL CARE
1
CHALLENGES IN TRANSITIONAL CARE 4

5. Challenges in Transitional Care
Brief Literature Review
The provision of quality transitional care is significant to all
patients since it helps to ascertain that the care needs of the
patients are fulfilled once they transition across different care
settings. According to McDonagh& Kelly (2010), challenges
associated with transitional care result in adverse negative
outcomes such as higher healthcare costs, unnecessary hospital
readmission rates, reduced life quality and satisfaction levels of
the patient as well as increased burden on the caregivers.
Coleman and Berenson (2004) note that hospital readmission
rates have increased by 37% especially among elderly patients
with stroke conditions. Coleman and Berenson (2004) further
add that the problem is projected to worsen with the expected
population increase of older adults. A number of studies have
established that adverse events take place within transitional
care and that elderly patients with complex care needs tend to
be at higher risks. Additionally, Allen et. al. (2014) maintains
that at least 49% of patients experience at least one instance of
distance-related medical errors or adverse events during the
transitional care period. Some of these events have been
reported to be preventable and that their severity could be
reduced through the use of earlier corrective actions as they are
often brought up by issues like diagnostic test follow-up errors,
falls, infections and drug mix-ups(Toles et. al., 2016). The
severity of these events may result in permanent disability or in
some cases death. At least 50% of the patients experiencing
such adverse conditions end up requiring extra health-care
services hence increased hospital readmission rates. LaMantia

6. et. al., (2010) notes that the existence of such transitional care
problems are brought about by ineffective and poor
communication and inconsistencies in the exchange of patient
information among the health care providers. In overall,
therefore, the literature proposes that there is need to conduct
additional research on transitional care in a bid to increase
understanding on how the quality of transitional care, especially
for the elderly patients, can be enhanced.
Methodology and Design of the Study
The study on transition care covers the hospital admission of
patients all the way to their being discharged to their homes
under the care of their caregivers. Hence the methodology of the
study will include the participant observation study on the
admission and discharge transition process. Such will involve
having holding conversations with some of the elderly patients
as well as their caregivers in regards to their awareness on the
providence of transitional care. The observation method will
also include a close analysis of the handling of the patients
throughout their admission process until they are discharged.
Such will include observing how the nurses receive the patients,
their conduct in emergency departments as well as how they
take care of the patients when in their medical wards.
Additionally, the observation method will also cover
information on the mode of interactions, coordination, and
dialogue between the patients and the health practitioners’ right
from the day of admission all the way to the day the patients are
discharged from hospitals.
Sampling Methodology
To recruit participants in the study, the sampling method was
used. Also, different municipalities were consulted and different
nursing leaders were selected using the sampling method, to
take part in the interviews hence enhancing the research
process. The interviews helped to shed light on the role played
by the nursing leaders in the transitional care process for older
patients. Hence the interviews were used to collect data and also
to dictate the key areas that the nurse leaders should address, as

7. a means to ascertain any existing challenges in transitional care.
The interviews were structured in a manner that starts with the
general information on transitional care, then on the transition
process and lastly on the experiences of the patients during the
transition care period. Such will help to collect key information
on all aspects of transitional care starting from when the
patients are admitted to hospitals all the way to when they are
released home and during their recovery period at home.
Necessary Tools
The research process will involve the use of different tools and
technologies. The primary consideration, however, is on
whether the technology information tools used in the healthcare
settings assist to ease the transitional care process. It is critical
to note that there exist multiple technologies used in the
provision of transitional care among them electronic health
records of the patients. These records contain information on
the patients and can easily be retrieved to enhance the treatment
process. Also, these records incorporate the clinical decision
support which enables the nurses and other key health care
personnel to make informed decisions regarding the well-being
of the patients. In essence, therefore, health IT experts perform
multiple roles with respect to fulfilling transitional care. It is
critical to capture all information pertaining to patient needs as
it helps to inform the transition care process in addition to the
medical history of the patients as well as what needs to be done
to help foster their quick recovery. As a result, it is important
that the IT health systems are designed in a manner that helps to
support the transition process, hence assisting patients to go
through the transition process with more ease. Additionally,
with the provision of information technology, healthcare
professionals can best communicate with the caregivers taking
care of the patients hence helping to improve to reduce the
instance of hospital readmissions.
Any Algorithms/Flow Maps Created
The main algorithm flow created during the research process is
the Fourier Transform. The Fourier transform is regarded as one

8. of the key algorithm methods to be used in healthcare settings
(Chen, 2016). Generally, the Fourier transform is a technique
used to break down complex signals thus enabling healthcare
providers to realize the variations in their activities and to
determine the best outcome needs for the patients. Such helps to
ensure that the healthcare personnel meet their objectives within
the organization and also to confirm whether the patients are fit
to be discharged home(Chen, 2016). The second algorithm that
will be created is the Mumps algorithm. The Mumps algorithm
was recently developed to meet the current patient needs in the
medical sector (Baronov &Evan, 2018). Hence, the Mumps
algorithm functions as an operating system which helps the
health care experts to understand the different aspects of patient
needs and to determine on the course of action to be taken
(Baronov &Evan, 2018). The Mumps algorithm is currently used
in the powering of the all the hospital department hence helping
to manage patient clinical records and enabling the healthcare
personnel to be fast in assessing the patient health care records
thus improving the overall workplace efficiency (Baronov
&Evan, 2018). The third algorithm method created is the use of
probabilistic data which is a technique that enables for different
computer searchers which are deterministic to be carried out.
The algorithm technique is very important since it ranks
different types of information depending on the likelihood of
the patients to adapt well to these methods hence helping to
estimate the time that it will take for the patients to remain in
hospital (Leyenaar et. al., 2016). Hence the probabilistic data
technique is important in the transitional care process as it helps
to see that patients remain in hospital long enough until they are
fit enough to be absorbed into the home care systems (Leyenaar
et. al., 2016). Lastly, medical algorithms are important in aiding
the decision-making process hence helping to promote safe
healthcare as it eliminates any errors on the part of the
healthcare personnel when provided health care services(Chen,
2016). With the increased cases of medical errors, the medical
algorithms come in handy in helping the health care personnel

9. to provide quality health care services and to understand the
patient needs hence effectively determining the patients who
require specialized care during the transitional care
process(Chen, 2016). Therefore, a medical algorithm in this
respect functions as a decision tree which helps to go about
complex decisions with the help of programming. In this case,
therefore, medical algorithms help to eliminate existing
uncertainties in the decision-making process hence improving
efficiency in the provision of transitional care.
References
Allen, J., Hutchinson, A. M., Brown, R., & 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), 346.
Baronov, D. V. & Evan J. B. (2018).Systems and methods for
transitioning patient care from signal based monitoring to risk-
based monitoring. U.S. Patent Application 10/062,456, filed
August 28, 2018.
Chen, E. T. (2016).Examining the influence of information
technology on modern health care. Effective Methods for
Modern Healthcare Service Quality and Evaluation (pp. 110-
136).IGI Global.
Coleman, E. A., & Berenson, R. A. (2004).Lost in transition:
challenges and opportunities for improving the quality of
transitional care. Annals of internal medicine, 141(7), 533-536.
LaMantia, M. A., Scheunemann, L. P., Viera, A. J.,
Busby‐Whitehead, J., & Hanson, L. C. (2010). Interventions to

10. improve transitional care between nursing homes and hospitals:
a systematic review. Journal of the American Geriatrics
Society, 58(4), 777-782.
Leyenaar, J. K., Desai, A. D., Burkhart, Q., Parast, L., Roth, C.
P., McGalliard, J., ... &Gidengil, C. A. (2016). Quality
measures to assess care transitions for hospitalized
children. Pediatrics, 138(2), e20160906.
McDonagh, J. E., & Kelly, D. A. (2010).The challenges and
opportunities for transitional care research. Pediatric
transplantation, 14(6), 688-700.
Toles, M., Colon-Emeric, C., Asafu-Adjei, J., Moreton, E., &
Hanson, L. C. (2016). Transitional care of older adults in
skilled nursing facilities: A systematic review. Geriatric
Nursing, 37(4), 296-301.
Running head: Implementation 1
Implementation 8
Implementation Phase #3
Challenges in Transitional Care
Due to the rising hospital readmissions rates which are as a
result of poor transitional care, it is important to develop a
program that will make sure the existing problems facing
transitional care are effectively taken care of and that in
specialized nursing is enhanced to promote the provision of

11. transitional care. At the present time, committee of health care
has suggested various interventions which require to be adopted
and implemented by the project manager to ensure transitional
care is improved especially in regards to taking care of elderly
patients. Some of the interventions that are great at decreasing
the rates of patient readmission include assessment of the
patient needs, patient education and medication reconciliation
(Morrison, 2016). It is very important that once patients are
discharged healthcare professionals should constantly
communicate with them and their caregivers get effectively
trained on how to handle various situations which are related to
medical conditions that are very common (Zenno, 2018).
Due to the interventions that have been proposed, the main aim
of the project is to address transitional care challenges by
interpreting the duties of homebased services, the importance of
caregiver support, partnerships within the community and the
relevance of new transitional care personnel. To ensure the
project is a success, the manager has developed a timeframe that
indicates when the project should be completed, a practical
budget, the manner in which resources will be distributed and
the tools to be utilized while conducting the project.
The Project’s Time Frame
ACTIVITIES
TIMESPAN
Evaluating the current condition of transitional care in health
care facilities. (Communication levels, patient admission and
readmission, the coordination between healthcare personnel and
nurses)
24 weeks
Evaluating the expertise level of nurses( Evaluating their
education and experience)
24 weeks

12. Visiting patients at home to evaluate the expertise level of
caregivers and determine how efficient they are.
24 weeks
Combining the results that have been acquired.
24 weeks
For the transitional care program to be endorsed, it requires a
defined timeframe indicating how various roles will be
achieved. Based on the project’s manager analysis, the planned
timeframe that is meant to bring significant improvements in
transitional care entails having six scheduled visits to
healthcare facilities for a period of two years. Within those two
years, there will be a close working relationship with healthcare
providers, elderly patients, caregivers as well as other key
stakeholders involved in transitional care. The first twenty-four
weeks (six months) will entail utilizing an observation method
to determine the current condition of transitional care in
healthcare facilities. During this period, notes will be taken
indicating how the healthcare facilities receive parents, how
they are admitted in emergency departments, the interactions of
nurses with elderly patients and coordination between the
caregivers and healthcare professionals when patients are
discharged.
The second six months will be utilized in evaluating nursing
expertise in relation to transitional care. Extensive research
indicates that using unspecialized nurses is a key challenge that
affects the effective provision of healthcare services. In
addition, past studies indicate that there is a huge difference in
the manner in which masters-level nurses provide services and
the manner in which nurses below the masters-level do it.
Therefore, the second six months will be utilized in determining
the level of education, training and experience among nurses
who offer transitional care. Again, the observation method will
be utilized to determine the differences between specialized and
unspecialized nurses. This entails evaluating the manner in
which they handle elderly patients, their coordination with
healthcare providers and their coordination with caregivers

13. (Hirschman, 2015).
The first twenty-four weeks (six months) of the second year will
be utilized in making home visits to evaluate the level of
expertise that caregivers have while taking care of patients after
they are discharged from health care facilities. During this
period, some of the activities that will be carried out include
engaging with caregivers to determine their preparedness level,
expertise and education and how effective they are able to
decrease the hospital readmission rates. Again, the period will
be utilized in determining the response of the patient to the care
offered by the caregivers and how fast they recover from their
various ailments after they are discharged.
The second twenty-four weeks of the second year will be
utilized in combining the acquired results and getting back to
sections which may have inadequate information to ensure the
results are free from biases. The two-year (96 weeks) time
frame set for the project will be adequate to make sure the
current challenges facing transitional are effectively addressed.
Project’s budget
For the project to be successful and all the activities within it to
be effectively conducted within the specified timeframe, a
budget will be developed to make sure all activities are handled
based on the allocated budget to ensure the complete costs are
not more than the current working revenues. According to the
manager of the project, a working a budget of $9,000 will be
enough for the project. The following is a breakdown on how
the $9,000 will be utilized.
1. Compensating employees ($4,000)- A team composed of ten
members will be used to acquire data from patients, caregivers,
nurses and healthcare providers. The team must be compensated
through offering reasonable wages and incentives.
2. Contract services ($1,500) – Various health care personnel
will be outsourced to be consulted about various issues in
regards to the project. The care providers must be compensated
through part-time wages whenever they are called upon to offer

14. their services
3. Supplies ($1,500) – For the project’s activities to be
effectively conducted, various supplies will be needed. Some of
the supplies include consumables, office supplies, computer
supplies etc.
4. Travel expenses ($1,000) – For the project’s activities to be
effectively conducted, extensive travelling is required therefore
with $1,000, all travelling expenses including air travel will be
catered for.
5. Overhead expenses (1,000) – Finally, $1,000 will be
allocated to catering for all the overhead costs to ensure all
administrative and daily operations costs are effectively taken
care of.
Project tools/resources
To ensure the project is entirely successful, various tools and
resources must be utilized to make sure key stakeholders are
involved in the project. Some of the major tools and resources
include materials of patients, hospital models and important
individuals that will be engaged in managing the project.
Patient/Family Resources
i. Family discharge planning checklist
This is a tool that ha various questions that should be answered
by both the caregiver and the patient before discharge.
ii. Next Step in Care
This is a website that offers guides and checklist to caregivers
and healthcare providers to ensure transitional care is improved
(Naylor, 2018).
iii. Patient PASS
This is a document that has all the requirements of a patient to
ensure he/she safely transitions from a healthcare facility to
his/her home.
iv. Personal health record
This refers to a record which indicates all the activities patients
should perform to better manage their conditions.
v. Patient discharge planning checklist
This is a tool which has various questions patients should

15. answer before being discharged. Some of the questions include:
where the patient will get care after discharge, the problems the
patient should look out for and what to do about them, whether
medical equipment is required and how bandages or shots
should be performed. Caregiver’s are also supposed to answer
various questions relating to options for continued care (Toles,
2016).
The mentioned resources/tools will be very important in
ensuring transitional care is improved through engaging all the
key stakeholders and using key documentation in the
transitional process to make sure patients safely transition from
hospitals to their homes. The resources/tools are also useful in
ensuring caregivers have adequate knowledge on how to manage
patients in order to decrease the rate of hospital readmissions.
References
Hirschman, K. B., Shaid, E., McCauley, K., Pauly, M. V., &
Naylor, M. D. (2015). Continuity of care: The transitional care
model. OJIN: The Online Journal of Issues in Nursing, 20(3), 1.
Morrison, J., Palumbo, M. V., & Rambur, B. (2016). Reducing
preventable hospitalizations with two models of transitional
care. Journal of Nursing Scholarship, 48(3), 322-329.
Zenno, A., & Gordner, C. (2018). Implementation of a
Transitional Care Program to Educate and Empower Pediatric
Patients with Diabetes Mellitus.

16. Toles, M., Colón-Emeric, C., Naylor, M. D., Barroso, J., &
Anderson, R. A. (2016). Transitional care in skilled nursing
facilities: a multiple case study. BMC health services research,
16(1), 186.
Naylor, M. D., Shaid, E. C., McCauley, K., Carpenter, D., Gass,
B., Levine, C., ... & Williams, M. V. (2018). COMPONENTS
OF COMPREHENSIVE AND EFFECTIVE TRANSITIONAL
CARE. Innovation in Aging, 2(Suppl 1), 202.
Running head: Project results 1
Project results 6
Results Phase #4
Challenges in Transitional Care
The results of the project
The main aim of the project was to determine the challenges
that transitional care is facing, determine the effect of
unspecialized care on transitional care and determine the
importance of specialized care in improving transitional care.
The study was able to determine five key challenges affecting
the effective provision of transitional care to elderly patients.
The challenges were as a result of the inability of the key
stakeholders to effectively conduct their roles. The key

17. stakeholders in transitional care include nurses, caregivers as
well as the patients themselves.
Caregivers
Based on the study, a majority of the elderly patients did not
have caregivers therefore making it difficult for the provision of
transitional care. For those who had the caregivers, they
indicated the caregivers played a crucial role in their
transitional care. For instance, the caregivers offered adequate
information to the nurses in regards to the patients’ health and
also provided sufficient self-care during the process of
admission and discharge. However, despite playing a great role
in improving transitional care, the caregivers were supposed to
consult healthcare personnel during the admission and discharge
processes to be able to get more information about the
condition, medications and surgical operations of a patient
(Loeffler, 2016). The study determined that in a majority of the
cases, caregivers were not effectively informed and were not
also prepared for a patient’s discharge process. The caregivers
often asked nurses whether the patients were completely ready
to be discharged from the healthcare facility. Again, the study
indicated that caregivers had high expectations from the nurses
and healthcare providers. They expected them to sufficiently
care for the patients until they fully recovered and were not
ready to extend any form of transitional care to their patients.
The characteristics of patients
According to the study, it was clear that most patients upon
admission suffered from different chronic ailments and other
minor diagnoses such as fatigue and diarrhea. However, during
admission, majority of the patients only indicated the main
chronic conditions and did not present the symptoms linked to
the minor diagnoses. Due to this, such patients were not
prioritized during the process of admission and were required to
wait at the emergency department. This led to the development
of various symptoms such as anxiety, dizziness, confusion and
walking problems when the patients were finally discharged.
Again, the study determined that majority of the elderly patients

18. acquired post-discharge infections. Based on the information
gathered from interviewing patients, most of them were
satisfied with the care offered to them during the process of
hospitalization but were largely dissatisfied by the long waiting
time during the process of admission (Albert, 206). In addition,
most patients indicated that they were not prepared to get
discharged which lead to confusion and anxiety in the transition
process.
The level of expertise of healthcare professionals
Based on the study, it was evident that formal routines in
relation to the admission and discharge processes were
available. However, when the study was being conducted most
of the physicians situated in the emergency department were
interns who had very little knowledge regarding admission
transitions. The study therefore identified a problem in their
technical part because healthcare professionals with adequate
experience and education should have been available to ensure
clinical assessment is effectively conducted during the
transition process. The study was also able to determine that the
chief physician and the ward nurse were responsible for
indicating the medication that a patient would take after
discharge. In addition, the two were responsible for identifying
those who were entirely ready to get discharged. In addition, the
study identified that nurses had very little information in
regards to a patient’s medical history during the discharge
process and this affected the transition process.
Information exchange
Based on the study, information during the process of transition
was transferred through three key methods which include
electronic, written and oral. At the time of admission,
caregivers were supposed to offer adequate information in
relation to the patients’ condition and health. However, in a
majority of the cases, the information provided was insufficient
majorly because of missing tests and nursing reports and
inadequate information about the current condition of the
patients. Due to these insufficiencies, healthcare professionals

19. hard a very difficult time in determining the accurate health
condition of a particular patient. Again, they had a difficult
time identifying the medical history of a patient and the right
medication for the identified condition (Vedel, 2015). In
addition, the study was able to determine that certain healthcare
facilities did not have an entirely integrated computer system
which resulted to various challenges in the transition process.
However, nurses played a crucial role in coordinating the
exchange of information during the process of transition
whereby at discharge, the nurses constantly communicated with
caregivers to offer more information about the health condition
of a patient.
Lack of patient assessment
After arriving at healthcare facilities, a majority of the elderly
patients presented morbidity and age-associated impairments.
The patients spent a lot of time in the emergency departments
before they could be evaluated by physicians. This lead to
frustrations and confusion among nurses who were taking care
of the patients (Orvik, 2016). Again it led to delayed patient
evaluation and introduced complications to the process of
transferring patients to their respective wards. In addition,
during the discharge process, patients were not subjected to a
systematic assessment which was because of not having
adequate information in regards to the history of the patient and
also letting patients get discharged based on the evaluation of
the primary disease only. The study determined that a majority
of the physicians mainly focused on the current medical
conditions of patients at the expense of their past diagnosis and
conditions. This is in a majority of the cases led to constant
patient readmissions.
Conclusion
The study attempts to identify the key challenges affecting the
effective provision of transitional care to elderly patients. The
results indicate that the challenges are interconnected and are
mainly as a result of healthcare personnel, caregivers and
nurses. This challenges should be effectively addressed through

20. multiple improvement strategies. The study utilized
observational data which indicated the unavailability of recent
studies and research on transitional care practices therefore
negatively affecting the provision of transitional care. It is
important to adopt the most appropriate strategies aimed at
enhancing the attitude of the key stakeholders involved in
transitional care. Again the strategies should improve the
knowledge and level of expertise of the different stakeholders
involved in the provision of transitional care. The strategies lay
a foundation of supporting organizational cultures that are
aimed at improving transitional care for elderly patients.
References
Albert, N. M. (2016). A systematic review of transitional-care
strategies to reduce rehospitalization in patients with heart
failure. Heart & Lung, 45(2), 100-113.
Loeffler, K. (2016). Geriatric intermediate care and transitional
care for frailty-related patients: Kerstin Loeffler. The European
Journal of Public Health, 26(suppl_1), ckw174-246.
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Running Head: CHALLENGES IN TRANSITIONAL CARE
1
CHALLENGES IN TRANSITIONAL CARE 7

21. Challenges in Transitional Care
Introduction to the Problem
Increasing cases of patient readmissions as soon as they are
discharged from hospitals have been on the rise thus indicating
existing challenges in the provision of transitional care.
Transitional care refers to the provision of continuous treatment
to the patients as they move from one health care facility to the
next or from the health facilities to their homes. According to a
study conducted by Ortiz in 2015, it was established that
“35.6% of hospital re-admissions within 30 days of discharge
are of elderly patients aged 75-84” (Ortiz, 2019). These
statistics indicate existing disparities in the provision of
transitional care thus resulting in the worsened conditions of the
patients as soon as they go home. Ortiz nonetheless establishes
that most caregivers admit to not having adequate knowledge
and experience on how to deal with the patients as soon as they
are discharged from hospitals (Ortiz, 2019). In most cases,
elderly patients suffering from acute conditions tend to be the
most vulnerable and easily fall ill once transitional care is
missing. Further according to Storm, “A majority of the deaths
involving elderly patients in home-based and community-based
care were as a result of lack of additional transitional care”
(Storm et. al., 2014). Similar results are echoed by Ye et. al.,

22. (2016), where in China policies were introduced in 2012,
hindering the provision of transitional care to patients by the
nurses, and as a result the practice saw at least 33% of the
elderly patients decline in their overall well-being and
functioning once left under the care of their caregivers.
Therefore, such statistics indicate that home-based care is often
marked by a lack of professional monitoring and also the
transition from a medical setting to a home setting often results
in medication mix-up which negatively imposes on the health of
the elderly patients.
Clearly Identify the Problem
Transitional care is marked by a lack of specialized nursing
interventions which results to the high rates of hospital
readmissions especially among the elderly patients suffering
from acute conditions. Also, there lacks clear communication
during the handing off of the patients to the caregivers, hence
resulting in increased confusion on the part of the care givers on
how to take care of the patients which results in their worsening
conditions (Morphet et. al., 2014). Additionally, a majority of
the caregivers are not adequately trained on how to provide
primary care to their patients and hence when left in their care,
their condition does not get any better forcing them to be
readmitted to hospitals. In other cases, the patients may lack
caregivers to look after them hence requiring a present
transitional nurse to help meet their medical needs, and once
these nurses are absent then the well-being of the patients is
compromised (Morphet et. al., 2014).
The existing challenges in transitional care are largely brought
about by the lack of specialized nurses with skills and
knowledge on professional transitional nursing care. According
to Storm et. al., (2014), the health and well-being of the
patients is threatened once there exist inconsistencies in the
provision of transitional care. In most cases, unspecialized
nurses are left to handle the transfer of the patients from one
facility to the next which makes their situation worse, since
such nurses are unaware of the significance of timely and

23. comprehensive communication during the transition period.
Moreover, when dealing with unspecialized nurses, there exist
inconsistencies in the emergency department nurses and those in
the ICU hence worsening the transition phase. Hence, the
existence of unspecialized nurses adds to more confusion on the
type of therapy required by the patients in their recovery phase
hence resulting in more complications (Ortiz, 2019). Thus, the
existence of specialized nurses in transitional care is key in
ensuring the provision of high-quality transitional care and also
in promoting the well-being of the patients.
Significance of the Problem to Nursing
The problem on transition care is significant to nursing since it
illustrates the need for specialized nursing care as a means to
overcome the existing inadequacies in transition care. Also, the
problem is rooted in the nursing profession as it seeks to
increase awareness on the importance of specialized nursing
care during transitional care. The problem further establishes
that the current nursing services involved in transition care are
inadequate and that often patients are often sent home without
lack of continuity care from professionals. The problem is also
significant since it informs of the weaknesses in nursing
communication, illustrating inconsistencies in the provision of
comprehensive information to foster continuity care. Also, the
problem makes it evident that poor professional coordination
among the nurses comes in the way of transitional care
hindering effective consultation of the provision of information
among the nurses and to the caregivers. Consequently, the
problem helps to illuminate the challenges encountered by
nurses when providing their nursing roles among them ensuring
that patients with no caregivers receive transitional care from
them and also informing the caregivers on how to deal with
patients. The problem is hence important in informing nurses on
their shortcomings and informing them on how to enhance their
nursing roles. Addressing transition care will help to improve
the role of the nurses in providing care for their patients and
hence it is essential that nurses acquire additional skills and

24. education on how to provide transitional care to patients.
Purpose of the Research
The main purpose of the research is to enhance the quality of
transitional care. Previous studies focused merely on the quality
of health care provided to the general population while omitting
the issues surrounding transitional care and as a result there
lacks knowledge and awareness on transitional care hence
resulting in the increased rates of patient readmissions.
Therefore, my research on the topic is intended to provide
adequate knowledge of the issues surrounding transitional care
and to bring attention to the stakeholders on the significance of
investing in the issue. Also, the research is intended to
enlighten the nurses on their areas of weaknesses and to
enlighten them on how they can improve their provision of
transitional care. Another key purpose of the research is to push
for the inclusion of transitional care in the nursing curriculum
to help impact all nurses with adequate knowledge on how to go
about the issue. Lastly, the research aims to create a platform
for more future research on the same hence raising awareness on
the severity of the issues on transitional care
Research Questions
The research will answer the following questions:
1. What are the main challenges facing transitional care?
2. How does unspecialized nursing impact on transitional care?
3. What is the importance of specialized nursing in the
provision of transitional care?
Master’s Essentials that Align with my Topic
Different master’s essentials align with my topic. For example,
Essential II establishes that the quality of patient care is
enhanced by effective organizational leadership, and in my
topic, I have highlighted how challenges in leadership like
communication and nurses’ corporation negatively impose on
the patient well-being. Also, Essentials III aligns with my topic
where it points out that inadequate specialized nursing is the

25. root cause of all the shortcomings in the provision of health
care and that master-level nurses should always be present in
any nursing facility as they are fully aware on how to handle
different patient needs. Likewise, my topic indicates that
unspecialized nurses result in the provision of low-quality
transitional care. Lastly, my topic aligns with Essential IX,
which establishes that the master’s degree level nurses tend to
have scientific understanding and also know how best to apply
the knowledge to practice. The Essential further notes that such
nurses can quickly influence the realization of positive health
care outcomes. Similarly, my topic notes that unspecialized
nurses cannot compare to the specialized nurses with a master’s
education, where the unspecialized nurses are not well vast on
the importance of transitional care while the specialized nurses
can quickly influence better transitional care results because of
their level of expertise and knowledge.
References
Morphet, J., Griffiths, D. L., Innes, K., Crawford, K., Crow, S.,
& Williams, A. (2014). Shortfalls in residents’ transfer
documentation: Challenges for emergency department
staff. Australasian Emergency Nursing Journal, 17(3), 98-105.
Ortiz, M. R. (2019). Transitional Care: Nursing Knowledge and
Policy Implications. Nursing science quarterly, 32(1), 73-77.
Storm, M., Siemsen, I. M., Laugaland, K., Dyrstad, D., &Aase,
K. (2014). Quality in transitional care of the elderly: Key
challenges and relevant improvement measures. International
journal of integrated care, 14(2).
Ye, Z. J., Liu, M. L., Cai, R. Q., Zhong, M. X., Huang, H.,
Liang, M. Z., &Quan, X. M. (2016). Development of the
Transitional Care Model for nursing care in Mainland China: A
literature review. International journal of nursing sciences, 3(1),

26. 113-130.