Transitional Care Interventions

Nurse prescribing has an important contribution to make in improving the service to patient’s clients within the primary health care setting, its benefits was highlighted in the crown

Post-discharge follow-up visit remains a critical factor in ensuring that patients continue to do well after they leave the hospital. The success of the team was measured based on data collected after 6 months of revamping the discharge clinic and implementing a phone call system to patients. They had been given a choice of a phone call for discharge follow up or to come in within 7-14 days and be evaluated post discharge.

The majority of the meting was focused on the care transitions program presentation and discussion. The presenters lay out was familiar as it was a community nursing care plan that included identifying, assessing, diagnosing, implementing, and evaluating the project she presented. The other members had a lot of questions about the process and a lot of time was spent on the social determinants of health. The presentation relied heavily on the in home part of the process and a nurse present on the board or for the presentation would have helped to connect the story for these patients in both settings. It was discussed that the elderly are a particularly vulnerable population during times of transition and that this program might help to bridge the vulnerabilities.

Across the country, new tools are being provided to states, localities, and community-based helping professionals to aid with the development of policies and prevention interventions designed to meet individuals in their environment and develop frameworks such as trauma-informed services that are tailored towards the private health and human services field to enhance the human services system’s ability to deliver person and family centered services in a cost effective manner.

These provisions have a huge effect on nurses. Hospitals are encouraging nurses and social workers to provide their patients with self-care education regarding medication management, follow-up care, and signs and symptoms of expected/unexpected conditions that could develop after discharge (Burton, 2012). Some hospitals are requiring their nurses to follow up with patients through weekly home-visits and phone calls (Coleman, n.d.). Hospitals using the care transitions model experienced a 30% reduction in 30-day readmission and were able to reduce patient care costs by 20% (Coleman, n.d.).

The practice intervention that I will be evaluating was undertaken in a local authority statutory children in care team. Kieran was made subject to an interim care order (S.38 Children Act, 1989) shortly after birth, following concerns that his parents were not meeting his basic needs in terms of food, warmth and nurturing. The mother Sarah has three children from a previous relationship who have all been removed from her care. Paul is the putative father and Kieran is their first child together. My role in this case was to assess the parenting capacity of Paul alongside concurrent planning for the adoption of Kieran. Paul and Kieran and were placed in a parent and baby placement as part of the assessment, however at the point of my intervention Paul had left the placement, leaving Kieran with the foster carers. Whilst this intervention was the subject of TMA 02 in my early stages of practice placement, there were further developments in that Paul was found not to be the father of Kieran and the birth father was in fact Sarah’s previous partner Martin, who was the father to her previous three children. Martin then made an application for the care of Kieran and therefore I was required to undertake a parenting assessment of him also. I have selected this case again as it demonstrates my continuing development as a critical practitioner in ‘applying reflection and curiosity to practice’ (The Open University 2016 a p.92) as well as how critical appraisal of further specialist

With a goal to obtain a 33% reduction in ED utilization by recently discharged patients, the MTF devised the following strategies to facilitate care transitions and improve communication from inpatient units to clinics and between clinics and patients. Collectively the interventions were recognized as Project Red Light and consisted of developing a Health Insurance Portability and Accountability Act (HIPAA) compliant process for sharing acute care admission/discharge information with appropriate clinics and outpatient providers as well as scheduling follow-up appointments prior to discharge or by the next business day following discharge. Other program interventions involved utilizing a multi-disciplinary approach to discharge planning consisting of input from Care Coordinators, Primary Care Managers, Social Workers, and Discharge Planners.

Nurses should be full partners, with physicians and other health professionals, in regarding health care in the United States(Institute of Medicine, 2011).Nurses should be full partners because who knows nursing and what nurses need better than a nurses themselves? In care environments, being a full partner involves taking responsibility for identifying problems and areas of waste, devising and implementing a plan for improvement, tracking improvement over time, and making necessary adjustments to realize established goals (Institute of Medicine, 2011).The expense of certain supplies and equipment could be decreased over time if nurses had more say in their environment and resources. On many floors in hospitals, certain supplies are not needed

There have been several policy-level measures to address the environment of the health care system and how it contributes to health disparities. First, as seen in Figure 3, the uninsured rate in the United States has declined by 43% following the implementation of the Affordable Care Act (ACA. According to National Health Interview Survey data, the increases in insurance coverage under the ACA were substantial across all races and ethnicities [11], increasing access to care for minorities which is an essential step in eliminating disparities. More notably, the ACA has also designated funding towards the diversification of the workforce. These measures took form in the U.S. Department of Health and Human Services Disparities Action

Occupational therapists use client-centered and holistic approaches to address the prevention and concerns of obesity. They collaborate with the client to form meaningful and effective interventions to modify daily life habits, roles, and patterns that contribute to obesity (AOTA, 2013). The occupational therapist will also collaborate with the client to design goals and address any occupations that are affected due to obesity (AOTA, 2013). Occupational therapy will aim to increase physical activity, adapt physical activity, and educate children about good nutritional choices (AOTA, 2013). Interventions for obesity may focus on prevention, remediation/restoration, adaptation/compensation, and maintenance programs (AOTA, 2013). Occupational

Nuttall (2013) that nurse prescribing is an important activity within HV, since the recommendations from the Department of Health (DOH) Crown reports one and two (1989, 1999). Following the government’s Cumberledge report (1986) which outlined the importance of nurses becoming prescribers within community settings to improve delivery of care, benefits impose more flexibility when assessing and planning medication treatment to service users (Nuttall et al 2011). Bishop et al (2015) see that nurse prescribing has vast many benefits from patient concordance with treatment, reduction of both hospital and general practitioners (GP) attendances.

HEALTH AND SOCIAL CARE INTERVENTION THAT MAY REVERSE THE FACTORS WHICH CONTRIBUTE TO THE LIKELIHOOD OF BECOMING FRAIL

As social workers, it is important to study the entire aspect of the individual. We must examine the individual past and see if their condition is trauma-related. It is the job of the social worker to identify the issue, in this case it would be a person who suffers from a mental illness and is placed in isolation when in jail or person and find the best solution for that issue. The solution to the issue may not be what’s written in a handbook or what we were thought, but sometimes we must find alternate resolutions. While we may not have the answers to combat the issue; if as social workers we could find the root cause of the issue that may help in the intervention process.

Which it should not be because not one case is the same when you look at factors involved.

Telepsychology is a relatively new development within the field of mental health service. The American Psychological Association defines it as the “provision of psychological services using telecommunication technologies. . . Telecommunication technologies include but are not limited to telephone, mobile devices, interactive videoconferencing, email, chat, text, and Internet (e.g., self-help websites, blogs, and social media).”(2016). Within the general category of telepsychology, psychological services that are delivered via the internet are referred to as “e-therapy”, “itherapy”, “cybertherapy”, and other similar names. E-therapy is a natural extension of our technological advancement, the growth of psychology as a field, and our ever increasing