The document outlines an assignment for a paper on improving a system of transition of care from hospitals to skilled nursing facilities. It instructs the student to identify a transition of care, describe key stakeholders and leadership strategies, and explain how systems thinking would inform an improvement plan. It provides feedback from a previous assignment and asks the student to incorporate that feedback into an annotated bibliography on their selected transition of care.

1. Assignment: System of Transition of Care Part 2 Paper
Assignment: System of Transition of Care Part 2 Paper ON Assignment: System of
Transition of Care Part 2 PaperI have attached the part I-Module 2 assignment which I
completed. The following assignment must use the references which are in part I that I have
attached.To prepare:Review feedback on your Module 2 Assignment 1 (from Week 4). You
should incorporate your Instructor’s feedback and continue to add to and refine your
annotated bibliography for your selected transition of care.Consider the nurse leader’s role
in achieving the IHI Quadruple Aim for this transition of care. (Hint: Draw from resources
on systems thinking and nurse leaders’ ability to influence innovation and
change.)Assignment (5–6 pages, not including title and reference page):Write a paper in
which you address the following:Identity your selected example of a transition of
care.Describe the key stakeholders that might be involved in this transition of care and the
leadership strategies you would use to engage and influence them.Explain how you, as a
nurse leader along with your healthcare team, would apply systems thinking when
providing a transition of care aligned with the IHI Quadruple Aim framework in order to
improve it. Explain the fourth aim and strategy you would use and why.Explain how
systems thinking would inform your improvement plan for the specific transition of care
you selected.Be sure your paper includes a title page and a reference page. You should also
resubmit your refined Annotated Bibliography.-The response clearly and accurately
identifies a transition of care.-The response clearly, accurately, and with appropriate detail
describes key stakeholders who may be involved in the transition of care. Leadership
strategies for engaging and influencing stakeholders are appropriate, clear, and thoroughly
described.-The response accurately and thoroughly explains in detail how to apply systems
thinking when providing a transition of care aligned with the IHI Quadruple Aim framework
in order to improve it. The fourth aim and strategy are appropriate, clear, and justified.-The
response accurately and thoroughly explains how systems thinking would inform the
improvement plan for the transition of care.md02assgn1broomes.d.6201_3.docUnformatted
Attachment Preview1 Annotated Bibliography on Transition of Care from Hospitals to
Skilled Nursing Facilities Dana Broomes Walden University NURS 6201 Section 3
Leadership in Nursing and Healthcare March 20, 2020 2 Introduction There are many
factors toward improving the quality of care for chronically ill older adults, enhancing
transitions within acute hospital settings, and improving patient handoffs to and from acute
care hospitals. The research indicates that there are existing gaps in care for these patients
and their caregivers during critical transitions that can lead to adverse events, unmet needs,

2. low satisfaction with care, and high rehospitalization rates (Naylor & Keating, 2008).
Studies also show that there are key elements to improving these transitions of care and
enhancing the of family caregivers which are to remain focused on the patients’ and family
caregivers’ needs, preferences, and goals, to utilize interdisciplinary teams guided by
evidence-based protocols, to improve communication among patients, caregivers, and
providers, and to use information systems to monitor care and outcomes (Naylor & Keating,
2008).The research suggests that comprehensive assessments of patients’ and caregivers’
needs should be performed at the time of the patients’ admissions to the hospital, since they
often lack the knowledge, skills, and resources to properly manage their follow-on home
health care (Naylor & Keating, 2008). The following annotated bibliography summarizes
five scholarly articles that address different components in the transition of care that nurse
leaders must focus on to safely manage patients’ continuity of care from acute care hospitals
to skilled nursing facilities (SNFs). Annotated Bibliography Dizon, M., Zaltsmann, R., &
Reinking, C. (2017). Partnerships in Transitions: Acute Care to Skilled Nursing Facility.
Professional Case Management, 22(4), 163–173. Retrieved from https://doi-
org.ezp.waldenulibrary.org/10.1097/ncm.0000000000000199 The purpose of this
collaborative study was to describe the efforts and results of the work done to address the
need to identify patients at high risk for unplanned readmission to hospitals 3 after being
discharged to skilled nursing (SNFs). According to the study, in 2004, 34% of Medicare
patients were readmitted to the hospital within 90 days of discharge, which resulted in an
estimated cost of $17.4, and older adults discharged to SNFs have higher rates of unplanned
readmissions due to their multiple comorbidities and complex inpatient care. Therefore,
Dizon, Zaltsmann, & Reinking conducted a comprehensive review to identify the unmet
needs of patients and caregivers that could ensure smooth transitions, educate patients and
caregivers, and facilitate communication between acute care facilities and SNFs. The
leadership teams of an acute care hospital in Northern California and eleven SNFs worked
together to focus on collaboration, communication, and competency by identifying problem
areas, objectives to address them, and actions necessary to achieve their established goals.
Assignment: System of Transition of Care Part 2 PaperThey conducted monthly meetings to
review unplanned readmissions that were evaluated by the hospital’s NP and SNF clinical
staff to identify trends and action items. These reviews helped to identify gaps in care and
opportunities for improvement. Two case studies were also presented in the article that
identified the major problem that the hospital was not consistent in providing correct
information to the SNFs which resulted in the formulation of three objectives of the
hospital-SNF partnership: the creation of standardized forms for transferring patients,
including checklists for hospital to SNF and SNF to ED transfers, incorporating transitions
work in the role of NPs to communicate directly with the bedside nurse with follow-up calls
post transfers, and enhanced communication by video conferencing. The case studies also
identified that end-of-life and palliative care was not adequately addressed by either agency
which led to more thorough assessments of patients’ and caregivers’ needs and more
collaborative communication with consistent messaging regarding end of life care options. 4
The multidisciplinary work between the hospital and contributing SNFs resulted in shared
accountability, better communication based on teambuilding, enabled smooth transitions,

3. and improved patient care. It involved bed-side staff and executive with shared decision-
making among facilities to improve workflow and communication between care settings.
The study also identified future work that can be done, such as including provider to
provider handoffs, collaboration with home health agencies, and the use of standardized
protocols at SNFs to improve patient care while decreasing healthcare costs. Hirschman, K.,
Shaid, E., McCauley, K., Pauly, M., & Naylor, M. (2015). Continuity of Care: The Transitional
Care Model.Online Journal Of Issues In Nursing, 20(3), 1. Retrieved from https://eds-b-
ebscohost-com.ezp.waldenulibrary.org/eds/detail/detail? vid= 1&sid=7fe09b20-b81d-
4202-8043-157089ce5a1e%40sessionmgr103&bdata=JnNpd
GU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=26882510&db=mnh This article by
Hirschman, Shaid, McCauley, and Naylor presents the Transitional Care Model (TCM), which
is an evidence-based, a nurse-led intervention focused on older adults at risk for poor
outcomes as they transfer between healthcare settings and attending providers. The TCM
focuses on the Triple Aim, improving care, enhancing outcomes for patients and family
caregivers, and reducing healthcare costs for chronically ill, older adults. Randomized
clinical trials have demonstrated the success of the TCM to improve acutely ill patients’
experiences, health, and quality of life outcomes with reduced rehospitalization rates and
overall healthcare costs of the chronically ill. The authors summarize the model’s core
components, which are screening, staffing, maintaining relationships, engaging patients and
family caregivers, assessing and managing risks and symptoms, educating and promoting
self-management, collaborating, promoting continuity, 5 and fostering coordination which
are interconnected and part of a holistic care process. The staffing used in the TCM uses
APRNs who are leading the care for their patients transitioning from acute hospital care and
have been identified as high risk for poor outcomes. The APRNs maintain the responsibility
for the daily delivery of transitional care services as well as overseeing other healthcare
team members. Assignment: System of Transition of Care Part 2 PaperThey screen patients,
conduct comprehensive assessments, establish trusted relationships with patients and
caregivers, educating them and promoting self-management to keep them engaged in their
healthcare plans. The APRNs also lead the way, promoting communication and connections
between hospital, post-acute, and community-based staff to facilitate the transfer of
essential information using secure email systems and electronic health records. The APRNs
engaged with patients, caregivers, and other team members work to ensure that patients
have smooth transitions of care with comprehensive treatment plans. The research team
established metrics to benchmark adherence and measure the program’s outcomes. There
is an ongoing study to help identify how health systems in America are adapting the TCM’s
core components to improve continuity of care through transitions. The article states that,
according to the Coalition for Evidence Based Policy, the TCM (2014) has been recognized
as a “top-tiered, evidence-based approach” that could have a significant positive effect on
Medicare beneficiaries transitioning from hospital to home. By adopting one or more of the
TCM’s core components to local practices, nurse leaders can implement this care
management approach to improve outcomes and assure that patients and their caregivers
have the and resources needed to help manage their care. Jusela, C., Struble, L., Gallagher,
N. A., Redman, R., & Ziemba, A. (2017). Communication 6 Between Acute Care Hospitals and

4. Skilled Nursing Facilities During Care Transitions. Journal of Gerontological Nursing, 43(3),
19–28. Retrieved from https://doi-org.ezp. waldenulibrary.org/10.3928/00989134-
20161109-03 The findings of the research conducted by Jusela, Struble, Gallagher, Redman,
and Ziemba also the need for improved TCMs and better communication of information
between acute care settings and SNFs for transitioning patients. The article cited an
Institute for Healthcare Improvement’s study from 2014 that reported poor communication
of medical information accounts for nearly 50% of errors during care transitions. These
transitions have been identified as “vulnerable exchange points,” and care plans from one
setting are often not communicated to the next care team. The study was a retrospective
convenience sample chart audit, and all patients admitted to the SNF from an acute care
hospital were examined. The checklist was based on local and national standards. It
revealed the following discrepancies: transferring physician contact information was
missing in 65%, medication lists were missing from 1%, steroid tapering instructions
missing from 42%, antiarrhythmic instructions missing from 38%, duration/indication of
anticoagulant medications missing from 25%, and antibiotic medications missing from 22%
of the patient charts. The accuracy and completeness of the discharging providers’
instructions also affect patients’ transitions. There were multiple implications based on the
results of this study. The data suggests the need for education and training of HCPs in both
SNF and acute care settings, including developing standardized forms, designating
leadership roles for accountability, and conducting quality improvement projects. The
researchers also suggested cross-continuum team meetings and the creation of policies and
procedures that allow for monitoring and collecting feedback 7 about discharge planning
processes, including information transfer, clinical outcomes, patient satisfaction, patient
understanding, and input from the provider and/or next care setting. Jusela, Struble,
Gallagher, Redman, and Ziemba identified nurse leaders as positioned to identify
recommended elements of data transfer for optimal patient outcomes and capable of
making recommendations for policy reform and quality improvement projects, removing
barriers to care. They suggest the creation of additional educational workshops that would
create awareness of institutional capabilities and/or barriers and would also facilitate
smoother transitions in care. Healthcare providers must be able to communicate effectively
and provide patients and caregivers with the resources that will enable them to be engaged
in their care plans. King, B. J., Gilmore-Bykovskyi, A. L., Roiland, R. A., Polnaszek, B. E.,
Bowers, B. J., & Kind, A. J. H. (2013). The consequences of poor communication during
transitions from hospital to skilled nursing facility: a qualitative study. Journal Of The
American Geriatrics Society, 61(7), 1095–1102. Retrieved from: https://doi-
org.ezp.waldenu library.org/10.1111/jgs.12328 According to King et al., there are multiple
inadequacies of hospital discharge information, including regular problems with medication
orders, little psychosocial or functional history, and inaccurate information regarding the
current health status of patients when patients are transferring to SNFs. Assignment:
System of Transition of Care Part 2 PaperThese inadequacies create delays in care,
increased SNF staff stress, frustrated patients and family members, and increased risk of
rehospitalization. With all the deficiencies identified in hospital?to?SNF transitions, poor
discharge communication was listed as the primary barrier to safe and effective transitions.

5. The article reports more than five million patients transition from hospitals to SNFs every
year, and nurses are primarily responsible for receiving and initiating these individuals’
care. 8 The objective of this study was to examine the patients’ transitions of care, the
barriers nurses experience, and the outcomes associated with variations in the quality of
transitions by analyzing detailed information obtained in focus groups and interviews with
practicing SNF nurses. The research suggests that high?quality, complete discharge
communication is crucial to safe and effective hospital–SNF transitions, and a lack of
transitional care training among health professionals might contribute to poor?quality
discharge communication since accreditation guidelines for physician and nursing training
programs are vague. Kerstenetzky, L., Birschbach, M. J., Beach, K. F., Hager, D. R., & Kennelty,
K. A. (2018). Improving medication information transfer between hospitals, skilled-nursing
facilities, and long-term-care pharmacies for hospital discharge transitions of care: A
targeted needs assessment using the Intervention Mapping framework. Research In Social &
Administrative Pharmacy: RSAP, 14(2), 138–145. Retrieved from
https://wwwsciencedirect-
com.ezp.waldenulibrary.org/science/article/pii/S155174111630374 6?via%3Dihub A
patients’ transition from a hospital to a SNF introduces the likelihood of medication errors.
According to this study, three-fourths of hospital to SNF admissions had at least one
medication discrepancy, and approximately 40% of medication errors are thought to be a
result of inadequate medication reconciliation procedures during transitions, with 20% of
these errors are believed to cause patient harm. This study reports on the development of a
logic model used to explore methods for minimizing patient medication delays and errors
while further improving handoff communication from hospital to SNF pharmacy staff to
improve the quality of care for patients transitioning from hospital to SNF. 9
Communication handoff for patients discharging to SNFs is an interdisciplinary effort
between providers, nurses, pharmacists, and social workers/case managers, but this
process is not standardized across disciplines. The study identified a common theme among
SNF staff of onedirectional discharge communication from the hospital with little
opportunity for feedback on patient care concerns. It was also determined that certain
communications are expected to occur as typical workflow, while some only occur if
clarifications are necessary. It was determined that the handoff process for hospital
discharge teams should be formalized, and the admitting SNF will receive handoff education
about the contents of the hospital discharge packet to eliminate gaps in transitional care.
Conclusion This annotated bibliography summarized five scholarly articles that address
different components in the transition of care that nurse leaders must focus on to safely
manage patients’ continuity of care from acute care hospitals to skilled nursing facilities
(SNFs). The studies identified key elements in improving these transitions of care and
enhancing the of family caregivers. Since multidisciplinary teams are involved when
transferring patient care, each member of the health care team must communicate clearly
with each other, patients, and their family members to comprehensively manage care
transitions to reduce healthcare costs, improve outcomes, and meet the needs of patients
and their caregivers. Reference: Naylor, M., & Keating, S. A. (2008). Transitional Care. AJN

6. American Journal of Nursing, 108(9), 58–63. Retrieved from https://doi-
org.ezp.waldenulibrary.org/10.1097/