Critical Analysis of a Selected Scenario from Caseworld - Case Study Example

Critical Analysis of a Selected Scenario from Caseworld Critical Analysis of a Selected Scenario from Caseworld Introduction Transition of care refers to the transfer of patients between care settings, health care providers or levels of care in the same location. The set of actions designed to ensure continuity and coordination of healthcare as the patient transfers often define the transitional care. The settings between which patients transfer include hospitals, primary and specialty care facilities, long-term care facilities and the patients’ homes (Ingo 2014). Transitional care should include a comprehensive care plan, logistical arrangements, coordination of caregivers and education of family members and patient in order to be effective. The transition of care process involves multiple persons who need to be part of the planning process. Persons involved include the patient, family, caregivers, physicians, pharmacists, psychologists and social workers (Dowshen and D’Angelo 2011). The process, therefore, affects not only the patients but also the other parties involved. This is especially true for family caregivers. The standardization of transitional care process usually seems poor. Discontinuity and fragmentation of care often characterize it. This paper focuses on the barriers to effective care transition, assessment necessary for effective transitional care planning and recommendations for potential areas of improvement of the transition of care. Impact of poor transition of care Much is at stake during the transition of care. The poor transition between care setting resulting in fragmented care and inefficiency affects the patient, family, and the community (Bryant & Nix 2012). Poor transition of care greatly compromises the health of the patient. It results in poor quality of care and patient safety. Studies show that about 19 percent of discharged patients experience adverse events within weeks of leaving the hospital (Naylor et al. 2013). Medication errors are the main cause of these adverse events and hence readmission. Medication errors include overuse, underuse or misuse of the prescribed medication, which causes the patients’ health to deteriorate. These medication errors are attributable to a lapse in patient and family caregivers education resulting in misunderstood instructions, drug interactions with food, alcohol and other drugs and duplicate therapy (Naylor & Keating, 2008). As a result, the patient’s health suffers and sometimes even causing preventable death. Poor transition of care also causes a significant burden on the family of the patient. Families are often the primary caregivers of the patient when they transfer back to their homes. Transitional care planning that ignores the family is ineffective and can lead to adverse effects on the patient and the family members ((AAOS) & Beck 2013). Transition of care has an impact on the financial, social, psychological and spiritual wellbeing of the patient’s family members. This is well exemplified in the Anne Greta White Case study. Anne is diagnosed and treated for depression when she becomes the primary carer for her mother. The change strains her relationship with her husband. They are constantly fighting about the move, the time she spends taking care of her mother, their children, and finances. The move also seems to be affecting her husband psychologically. Anne notices that her husband’s behaviour has become more erratic, and he is taking out his frustrations on her. John has also commenced drinking alcohol again. Anne also notices that her son has become distant and is spending much time away from home. She can no longer connect to her son. The transition of care is also affecting the health of her daughter. Jessica’s asthma is primarily triggered by the change of weather and Anne blames herself that her daughter has asthma. Flawed transition of care causes a significant impact on the community as well in terms of finances (Peters et al. 2011). Patient readmission affects the country’s economy. It results in extended hospital stays, a cost to the taxpayers. Employers also feel the burden of the fragmented transition of care. Patients and the family members leave work for extended periods to stay at the hospital (Boltz 2012). These unavoidable sick days cause decrease productivity and accumulated loss of revenue. Factors affecting planning for transition of care Transitional care planning assessments Assessment is necessary to curb the impact of the poor transition of care. They provide information that helps to identify problems the patient, family and caregivers may face during the transition period and hence minimize adverse events and cases of readmission (Shippee-Rice et al. 2012). The disease or condition affects not only the patient’s health but also ability to work, mental health, family, social relationships, spiritual well-being and financial instability. Therefore, assessments should encompass all these areas to identify potential problems. Issues faced are unique to each patient and family. For example, some may face problems of obtaining the special home equipment, psychological problems and financial challenges, issues not faced by other patients and families (Cooper & Gosnell, 2014). Therefore, the transitional planning should be tailor-made for all patients. This will be based on assessments carried out. By identifying potential problems and hence the kind of support the patient and families need the general number of rehospitalisation deceases. Assessments should also be carried out as part of the routine care to identify changes and hence problems that might arise (Allen et al. 2014). This will ensure they get the right support at the right time. Transitional care affects multiple individuals and different life aspects. A comprehensive transitional planning assessment, therefore, should include multi-disciplinary professionals (Naylor et al. 2011). These professionals may include physicians, psychologists, nurses, physical therapists, nutritionists, occupational therapists, social workers and chaplains depending on the requirements of the individuals involved. Assessments carried out during the transitional care planning should include: Physical assessment The physician should carry out the first part of this assessment. This is the assessment of the patient to transition. Upon diagnosis, the patients medical history information and data of the disease should be well documented (Cooley & Sagerman, 2011). This information is necessary to predict the progression of the disease, and hence the care regime required. The assessment focuses on the patient’s health, treatment plan and changes in the disease as a result of factors including treatment and nutrition. The physician assesses and documents the manifesting symptoms of the disease during the period of transition and determines the stage of the disease (Jansink et al. 2010). The treatment being administered is also assessed, and the side effects and expected intervention changes as the disease progress documented. The patient, family, and caregivers should be educated about the disease, treatment and expected progress (Stanhope & Lancaster 2013). Education about the medication is vital. Nutritionists should also be involved to assess the nutritional status of the patient. Nutrition affects the treatments effectiveness. The patients should be educated on drug-food interactions to avoid adverse events upon discharge. Psychological and mental health assessment This is a key aspect of the transitional care planning process. Transition of care may be a stressful process for the patient, as well as the family. This assessment will help to determine the kind of support the patient and the family will require during the transition (Series et al. 2011). In the case study, Anne Greta White is diagnosed and treated for depression. This exemplifies the need for mental assessment during the transitional care planning process. Anne visits a counsellor at the recommendation of a caregiver support network. A support system might have helped Anne before she started to suffer from depression. It also appears that her husband’s behaviour is becoming erratic. John also takes up drinking. He is exasperated and is taking it out on Anne. Dylan, her son, has become distant and is spending long periods at the local skate park. Anne is dealing with these issues after they arose. However, these issues could have been prevented with effective planning and knowledge made available by physiological assessment of the family. Psychologists at the planning stage should assess the patient’s and the family’s feelings about the disease and the upcoming transition of care (Allen et al. 2014). This will be helpful in avoiding depression, anxiety, cognitive dysfunction, post-traumatic stress disorder, among other mental health issues that may arise. Counselors, support groups, and mental health workers should be recommended at initial stages of transition of care (Ingo 2014). Psychological assessment should also include an assessment of beliefs, values, motivation, family stability, communication patterns, history of psychiatric illness and the family goals of the therapy. Spiritual assessment Patient and family spirituality may play a role in the therapeutic intervention. Studies points that for spiritual patients, belief in a superior being and their power over the disease may enhance treatment (Ingo 2014). This assessment should include an evaluation of religious affiliation, sense of spirituality, spiritual distress and social support of the religious community. Social assessment The financial assessment is key to this planning process. Diseases that require transitional care often cause financial strain to the family of the patient. The various options of treatment and financial impact should be assessed, and the patient and family presented with options so that they can select one best suited to their financial capability. Various financial support systems available should also be presented to them (Salas & Frush, 2012). Other factors to be assessed include available support systems, insurance assessment, employment flexibility, community resources and accessibility to resources. Legal assessment The patient and family should be advised in the transitional care and disease. The planning process, therefore, should include legal assessment including will preparation, the power of attorney, resuscitation status, and guardianship for dependents. Barriers to effective care transition The main barrier to effective care transition is ineffective communication (Okumura et al. 2010). Communication is key to a smooth transition. It is necessary for hospital physician and nurses to communicate with the patient, family and caregivers for effective transition and hence avoiding the occurrence of adverse events, which may necessitate rehospitalization. Lack of an integrated care system is another key barrier (Ingo 2014). Patient treatment involves many professionals working in a system that is not integrated. This promotes communication breakdown affecting transitional care. The process is also affected by the lack of longitudinal responsibility across settings. Transition of care is affected by various social factors. Therefore, failure to recognize the language, educational and cultural differences is a barrier to effective care transition. Caregivers are usually motivated by payment. Performance incentives and compensation are normally not aligned with the goal of maximizing the quality of transition of care (Agrawal 2013). They are paid for services provided as opposed to outcomes. This does not emphasize the importance of quality care hence greatly affect the transition of care. Transition of care is also challenged by lack of standardized process (Okumura et al. 2010). Information systems are also incompatible. There is also a gap in the education of healthcare professionals when it comes to coordination, and team-based treatment required in the transition to care. Areas for improvement of the transition of care The communication between healthcare providers, patients and caregivers is key during the transition. The problem of communication between healthcare providers, patients, and caregivers during transition greatly affects the transition of care. Communication is vital in achieving the desired outcome. The transfer of accurate information in a timely fashion across the different settings is crucial for the effective execution of care transitions (Paniagua 2011). The systems are usually disconnected involving for example hospitals, care facilities, care providers at home and insurance companies. It is critical to transfer accurate information between these entities. Breakdown in communication leads to adverse effects mainly as a result of medication error leading to negative effects on the patient’s health and sometimes even death. Education is key to improving communication. It is critical to educate the parties, family, and caregivers in the transition process. Health care providers should also be educated on coordination and team-based approach to the transition of care to improve communication (Paniagua 2011). Another area that needs improvement is the transition from the emergency department and other transition settings. Standardization of the medical system processes and implementation of electronic medical records The current treatment process involves different professionals focusing specific areas of the treatment. This further encourages communication breakdown. A holistic manner of treatment should be adopted to improve the transition of care and the health care system in general. Electronic medical records will address the issue of incompatible information. It will encourage the flow of information and improve accessibility to information ((AAOS) & Beck 2013). Electronic medical records will maintain complete and accurate medical history of patients that can be accessed by the different settings. It will aid in medical reconciliation. Accountability Patient care involves a number of professionals. These professionals should have clearly defined roles so that they can be held accountable for the role they play. For effective health care provision, points of accountability should be defined (Naylor & Keating 2008). This would ensure accountability in all setting and individuals involved. Pharmacist involvement in transitions of care A medication error is the main cause of rehospitalization after discharge. Pharmacists can take up the responsibility of monitoring patient medication as they transit between settings. They can identify drug-to-drug interaction, adverse drug effects and duplication in medication regime and, therefore, should be actively involved in the transition of care (Cooley & Sagerman 2011). Pharmacists should also be actively involved in the education of patient, family and caregivers about the medication prescribed. Pay-for-performance The payment systems should be adjusted to align incentives that encourage improvements in the transition of care. Performance measure should be introduced to encourage quality transition of care. Pay-for-performance will promote improved coordination of care between settings. Focus on the case study The process of planning for transition care should take into consideration issues the patient, family and caregivers are likely to face. Transition of care in the patient’s home requires critical planning since it is likely to affect all the individuals living in the homestead. In this case study, the planning process seems to have been ineffective. Psychological effects John is affected negatively by the event though he agreed to the plan to move. His behavior has become more inconsistent, and Anne believes that he has commenced drinking alcohol again. John has become increasingly anxious and angry and seems to be taking this out on Anne. He is constantly fighting with his wife about the move, having to spend all of her time caring for Greta, the kids and about money. Dylan is also psychologically affected by the changes. Anne feels her son has gradually become more distant and spends a great deal of time away from home. Anne cannot seem to connect as she used to with her son. Psychological assessment in the planning presses should have recognized the impact of the transition to care to a pre-teen adolescent and offered the necessary support. Anne, the primary carer seems most affected by the move. Even though, she attends a carer support group, the challenges of transition care are difficult to overcome and is diagnosed with depression. Her relationships are suffering due to the changes. She is constantly fighting with her husband about the move, having to spend all of her time caring for her mother, the kids and about money. She cannot seem to coordinate well as she used to with her son making her feel like she is failing as a mother. She also blames herself for Jessica’s asthma. Anne is, however, able to get effective medical care. The carer support group recommends a counsellor. She talks to the counsellor and is diagnosed and treated. Communication between the counsellor and her general practitioner Dr. Mary Louis effectively put Anne on the track to recovery. The practitioner prescribes Sertraline and explains the side effects she should expect. Anne’s treatment shows effective patient care of the Australian Healthcare System. It involves support, communication and coordination, patient education and treatment follow-up. Financial effect The case study exemplifies the financial impact of transition care. Anne resigned from her job as a hairdresser in order to become the primary carer for her mother, Greta. The family’s finances are strained, and it is one of the issues causing distress in her marriage. Health impact The family had to relocate to a new environment. Jessica had a recent hospital presentation due to an acute asthma attack. The asthma is primarily triggered by the change of weather. Jessica also receives effective treatment, and the condition is stabilized. Impact of Transition of care on the patient, Greta Cultural expectations are one of the factors that affect the transition of care (Ingo 2014). Greta and Anne believe it is Anne’s duty to care for her mother. Even when a high-level care nursing home is recommended when Greta’s health deteriorates, Anne has mixed feelings about it. Greta suffered a recent CVA. She has been receiving home physiotherapy once a week from a PT. She, however, has started to become forgetful, agitated and has increased falls. The information delivered in this case study is not adequate for the formation of an effective plan for the continuing care of the patient. The following information should be available: Psychological evaluation for John, Jessica, Dylan and Greta, Jessica’s medical history and treatment plan. Additionally, Anne’s depression diagnosis and treatment plan, John’s back injury information and Greta’s medical history and treatment plan. The family’s financial information should also be included. Bibliography (AAOS), A.A. of O.S., & Beck, R., 2013, Advanced emergency medical technician transition manual, Jones & Bartlett Publishers, Sudbury, MA. Agrawal, A., 2013, Patient safety: a case-based comprehensive guide, Springer Science & Business Media, New York. 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 Serv. 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