NURS FPX 6610 Assessment 3 Transitional Care Plan

NURS FPX 6610 Assessment 3


Capella University

FPX6610: Introduction to Care Coordination

Instructor’s Name

February 2024

NURS FPX 6610 Assessment 3 Transitional Care Plan

Transitional Care Plan

In the scenario presented, addressing the transitional care needs of Mrs. Snyder, a terminally ill patient, underscores the critical importance of effective care coordination during healthcare transitions. By navigating the complexities of Mrs. Snyder’s care journey, healthcare professionals can glean valuable insights into the challenges and opportunities inherent in transitional care management. Through this assessment, key elements essential for safe and high-quality transitional care will be explored and barriers to effective communication and information transfer will be identified. The aim is to propose innovative strategies to optimize patient outcomes in scenarios akin to Mrs. Snyder’s.

Key Elements & Information Needed for High-Quality Treatment

Medical History and Diagnosis

A detailed review of Mrs. Snyder’s medical history, including specifics of her cancer diagnosis, treatment trajectory, and current symptoms, is essential. Understanding the intricacies of her medical background provides valuable context for crafting an effective care plan tailored to her individual needs.

Physical Assessment

A comprehensive evaluation of Mrs. Snyder’s physical condition is necessary. This assessment informs decisions regarding pain and symptom management strategies and helps ensure her comfort and well-being.

Psychological and Emotional State

Assessing Mrs. Snyder’s psychological and emotional state, including levels of anxiety, depression, and coping mechanisms, is crucial for providing holistic care. Understanding her mental health status allows for the implementation of supportive interventions and tailored emotional support.

Social Support Network

Identifying available family members and other caregivers who can provide assistance and emotional support is essential. Evaluating Mrs. Snyder’s social support network helps in developing a comprehensive care plan that addresses her needs effectively and fosters collaboration among caregivers.

Pain and Symptom Management

Developing a personalized approach to alleviate Mrs. Snyder’s pain while minimizing potential side effects of treatment is paramount. Regular assessment and adjustment of pain medications and symptom management strategies based on patient feedback and clinical evaluation are critical components of this process.

Communication and Education

Clear and empathetic communication with Mrs. Snyder and her family regarding her prognosis, treatment options, and goals of care is imperative. Providing comprehensive education about different care options empowers them to make well-informed decisions aligned with their preferences and values.

Coordination of Care

Effective coordination of care across healthcare settings and disciplines is fundamental to ensuring seamless transitions and optimal outcomes for Mrs. Snyder. Collaborating with healthcare providers and coordinating home healthcare services supports her care needs in her preferred setting.

Advance Care Planning

Engaging in discussions about Mrs. Snyder’s end-of-life care preferences promotes alignment and reduces conflicts during critical decision-making moments. Advance care planning ensures that her wishes regarding resuscitation, life-sustaining treatments, and goals of care are respected.

Cultural Sensitivity and Religious Beliefs

Respect for Mrs. Snyder’s religious beliefs and preferences is essential in delivering patient-centered care. Identifying facilities or services that can accommodate her cultural and religious needs demonstrates a commitment to honoring her values and ensuring her comfort and dignity.

Emotional and Spiritual Support

Providing emotional and spiritual support tailored to Mrs. Snyder’s individual needs enhances her overall well-being and quality of life during this challenging time. Access to counseling services, support groups, and spiritual care offers opportunities for coping and reflection.

Ongoing Follow-Up and Evaluation

Regular follow-up and evaluation are essential for monitoring Mrs. Snyder’s condition and ensuring that her care plan remains appropriate and responsive to her evolving circumstances. Assessments of patient and family satisfaction with care provide valuable insights for continuous improvement in transitional care processes.

Importance of Key Elements of a Transitional Care Plan

The comprehensive assessment serves as the foundation of transitional care planning by providing a detailed understanding of the patient’s medical history, current condition, and individual needs. Without a thorough assessment, healthcare providers may overlook crucial aspects of the patient’s health, leading to inadequate symptom management or inappropriate care decisions (Williamson et al., 2020). Inaccurate or incomplete information during this phase could result in misdiagnosis, ineffective treatment plans, or failure to address underlying health concerns. Therefore, a comprehensive assessment ensures that care plans are tailored to meet the unique needs of each patient, ultimately improving the quality of care and patient outcomes.

Effective pain and symptom management are essential components of transitional care, especially for patients with serious illnesses like Mrs. Snyder. Proper management not only alleviates discomfort but also enhances overall well-being. Inadequate pain management due to missing or inaccurate information can result in unnecessary suffering, decreased functional ability, and diminished quality of life for the patient. Moreover, poorly managed symptoms may lead to increased hospital readmissions or emergency room visits, adding to healthcare costs and burdening the patient and their family (Williamson et al., 2020). Therefore, attention to detail and accurate information in symptom management are critical for optimizing patient outcomes during transitions of care.

Communication and education play pivotal roles in ensuring that patients and their families are empowered to make informed decisions about their care. Clear communication fosters trust between patients and healthcare providers, facilitates shared decision-making, and reduces anxiety and uncertainty during times of transition (Mata et al., 2021). Inaccurate or inadequate information during this stage can lead to misunderstandings, unrealistic expectations, or uninformed decisions that may not align with the patient’s goals and preferences. Consequently, comprehensive communication and education efforts are essential for promoting patient autonomy, enhancing satisfaction with care, and ultimately improving outcomes during transitional periods.

Importance of Effective Communication

Robust communication facilitates the exchange of crucial information regarding the patient’s condition, treatment plan, and preferences between different care providers. In Mrs. Snyder’s case, this would involve transmitting accurate details about her diagnosis, prognosis, medication regimen, and palliative care preferences to ensure continuity of care as she transitions between hospital, hospice, and community settings.

Inadequate communication among healthcare providers and community agencies can have profound implications for patient outcomes and the quality of care. Without clear and timely information sharing, there is a risk of fragmented care, leading to medication errors, duplicated tests, and unnecessary hospital readmissions (Kwame & Petrucka, 2021). In Mrs. Snyder’s case, deficient communication could result in suboptimal pain management, inadequate support for her psychological and emotional needs, and delays in addressing emergent concerns, ultimately diminishing her quality of life during this critical phase of care.

Furthermore, inadequate communication may exacerbate patient and caregiver distress, leading to heightened anxiety, frustration, and feelings of abandonment. Mrs. Snyder and her family rely on healthcare professionals to guide them through this challenging period, and poor communication can erode trust and confidence in the healthcare system. Moreover, when essential information is not effectively transmitted, patients and their families may feel isolated and unsupported, exacerbating their emotional burden and impeding their ability to cope with the challenges of terminal illness (Kwame & Petrucka, 2021).

Barriers to the Transfer of Accurate Patient Information

One significant barrier in the case of Mrs. Snyder is the lack of standardized processes for information exchange between different healthcare settings. Without standardized formats and protocols for documenting and transmitting patient information, there is a higher risk of errors, omissions, and misinterpretations during the transfer process (Yaqoob et al., 2021).

Another potential barrier is the fragmentation of electronic health record (EHR) systems. If the sending organization and receiving facility use incompatible EHR systems or if there are interoperability issues between systems, it can hinder the seamless transfer of patient data (Hansen & Baroody, 2023). This can lead to delays in accessing critical information, discrepancies in medication lists, and challenges in reconciling care plans, jeopardizing patient safety and continuity of care.

Furthermore, human factors such as workload, time constraints, and competing priorities among healthcare professionals may impede the accurate transfer of patient information. In busy clinical environments, healthcare providers may overlook important details, fail to document changes in the patient’s condition or treatment plan, or neglect to communicate essential information to the receiving facility (Austin et al., 2021). This can result in gaps in care coordination and compromise the integrity of the transfer process. 

Strategy to Establish Absolute Understanding of Continued Care

The case involving Mrs. Snyder, involves implementing a comprehensive electronic health record (EHR) system with integrated decision support tools and real-time communication capabilities. This EHR system would allow for the seamless transfer of patient information across healthcare settings, minimizing the risk of errors and enhancing care coordination.

Firstly, the EHR system ensures that all providers have access to the most up-to-date and accurate information regarding the patient’s medications, including dosage, frequency, and any recent changes or adjustments (Hernandez et al., 2020). Secondly, the EHR system assists providers in adhering to evidence-based guidelines and best practices when developing the patient’s plan of care (Kwan et al., 2020). For example, the system could generate alerts for potential drug interactions, contraindications, or dosage adjustments based on the patient’s medical history and current medications, helping to prevent medication errors and adverse drug events.

Additionally, through secure messaging platforms and telehealth functionalities, providers can easily exchange information, discuss treatment plans, and coordinate follow-up care, ensuring continuity and consistency in the patient’s management across different settings (Potter et al., 2020). Furthermore, the EHR system could incorporate patient engagement features, such as patient portals or mobile applications, allowing patients and their caregivers to access their medication lists, care plans, and appointment schedules remotely (Potter et al., 2020). This promotes patient empowerment and active participation in their own care, while also serving as a valuable resource for providers to verify and confirm patient-reported information during care transitions.


Mrs. Snyder’s care journey vividly illustrates the significance of robust transitional care practices in contemporary healthcare settings. By integrating comprehensive care plans, promoting seamless communication among healthcare stakeholders, and addressing barriers to information transfer, healthcare systems can enhance patient safety and improve overall healthcare outcomes. Furthermore, leveraging innovative strategies, such as technology-enabled medication reconciliation, can further fortify transitional care processes. Through continued dedication to refining and implementing these strategies, healthcare organizations can ensure that patients like Mrs. Snyder receive the highest quality of care during critical transitions in their healthcare journey.


Austin, E., Blakely, B., Salmon, P., Braithwaite, J., & Williams, R. (2021). Identifying constraints on everyday clinical practice: Applying work domain analysis to emergency department care. Human Factors: The Journal of the Human Factors and Ergonomics Society, 001872082199566. 

Hansen, S., & Baroody, A. J. (2023). Beyond the boundaries of care: Electronic health records and the changing practices of healthcare. Information and Organization, 33(3), 100477. 

Hernandez, T., Blayney, D. W., & Brooks, J. D. (2020). Leveraging digital data to inform and improve quality cancer care. Cancer Epidemiology, Biomarkers & Prevention, 29(4), 816–822. 

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(158), 1–10. 

Kwan, J. L., Lo, L., Ferguson, J., Goldberg, H., Diaz, J. P., Tomlinson, G., Grimshaw, J. M., & Shojania, K. G. (2020). Computerized clinical decision support systems and absolute improvements in care: Meta-analysis of controlled clinical trials. BMJ, 370, m3216. 

Mata, Á. N. de S., Azevedo, K. P. M., Braga, L. P., Medeiros, G. C. B. S., Segundo, V. H., Bezerra, I. N. M., Pimenta, I. D. S. F., Nicolás, I. M., & Piuvezam, G. (2021). Training in communication skills for self-efficacy of health professionals: A systematic review. Human Resources for Health, 19(1), 1–9. 

Potter, D., Brothers, R., Kolacevski, A., Koskimaki, J. E., McNutt, A., Miller, R. S., Nagda, J., Nair, A., Rubinstein, W. S., Stewart, A. K., Trieb, I. J., & Komatsoulis, G. A. (2020). Development of cancerlinQ, a health information learning platform from multiple electronic health record systems to support improved quality of care. JCO Clinical Cancer Informatics, 4, 929–937. 

Williamson, S., Hack, T. F., Bangee, M., Benedetto, V., & Beaver, K. (2020). The patient needs assessment in cancer care: Identifying barriers and facilitators to implementation in the UK and Canada. Supportive Care in Cancer, 29(2). 

Yaqoob, I., Salah, K., Jayaraman, R., & Al-Hammadi, Y. (2021). Blockchain for healthcare data management: Opportunities, challenges, and future recommendations. Neural Computing and Applications, 34(2), 1–16.


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    NURS FPX 6610 Assessment 4

    Name Capella University FPX6610: Introduction

    NURS FPX 6610 Assessment 3

    Name Capella University FPX6610: Introduction

    NURS FPX 6610 Assessment 2

    Patient Care Plan NURS FPX

    NURS FPX 6610 Assessment 1

    NURS FPX 6610 Assessment 1

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