Development of an Educational Tool: Transitional Healthcare Planning in the Community Setting

Monday, 30 October 2017: 2:45 PM

Sharon Caldwell Jones, DNP
Pamela Waynick-Rogers, DNP
School of Nursing, Vanderbilt University, Nashville, TN, USA

Background: The Institute of Medicine (IOM) identified the core needs for the healthcare system as: safe, effective, patient-centered, timely, efficient, and equitable (5). Yet as the healthcare system has grown in scope and complexity, these aims are not always reached, especially when a patient transitions from an inpatient setting to another care setting such as home. The Affordable Care Act (ACA) reduces payments to hospitals with excess readmissions and the Center for Medicare & Medicaid Services (CMS) with the Hospital Readmission Reduction Program (CMS, 2014). For example, hospitals experiencing higher readmission ratios for conditions such as acute myocardial infarction, CMS will reduce payments to the organization. As a result, healthcare organizations are being more proactive in preparing patients for discharge and assessing for potential transition to community issues with care coordination (IHI 2011).

The American Nurses Association (ANA) and the American Association for the Colleges of Nursing (AACN) both support the active role of nurses to facilitate effective transitions from inpatient to outpatient settings. A recent ANA Position Statement asserts that care coordination should be “infused throughout registered nurses’ curriculum” (7), and the ANA White Paper on Care Coordination echoes the importance of including care coordination in registered nurse education (8). In addition, the AACN Essentials for Baccalaureate Education for Professional Nursing Practice (9) state that nursing education should prepare the graduate to “facilitate patient entered transitions of care “ (p.31) ultimately to promote safe care and that clinical practice must expose the students to “accelerated care transitions” (p.34).

Objective: Develop a meaningful educational assignment that prepares baccalaureate nurses to understand the complexities of healthcare continuity as they plan for patients and families to transition from the hospital to the community.

Design: The Transitional Nursing History (TNH) Tool introduces pre-licensure students to quality transitional healthcare planning needs and to the essential role nurses have in the process. The TNH represents a collaboration between inpatient and community health clinical sites. The TNH promotes nursing students’ understanding of the importance of transitional healthcare planning for patients/families and its positive impact on health outcomes within the larger medical center system. The collaborative process, the importance of nursing role(s), and the interprofessional nature of this transitional process are emphasized.

In order to incorporate transitional care planning within the foundation of Healthy People 2020 (USDHHS, 2015) Determinants of Health (DoH) factors, the TNH is an assignment for 145 Community Health (CH) students. The TNH assignment links a selected patient from each student’s inpatient clinical rotation with his/her CH clinical site. Students chose a patient from their hospital clinical assignment, assess the medical history and current medical status in light of the community resources and barriers, and determine the education needed for that patient and family to have a successful transition when leaving the hospital and returning to the community. The assignment culminates with each student presenting their TNH using a concept map to their CH group. The concept map included student-nurse interventions for each DoH category as well as interprofessional referrals and suggestions for patient/family advocacy. Each student presents the implications for effective home management of medication and other aspects of care, when transitioning to the community.

Results: Students report a greater appreciation of the need to know community resources and barriers after completing this assignment. The TNH “makes them think” about the transitional care planning ramifications for their actual patient and family; medication prescription fulfillment, educational needs for accurate medication adherence and dosing. In addition, potential safety risks of abnormal laboratory values have new meaning when applied to the transitional care planning experience by the students. Post-assignment, inpatient clinical faculty report students have an improved comprehension of the patient/family needs as they transition from inpatient to outpatient settings.

Summary Recommendations: Administrative support and course coordinator collaboration are essential to provide designated time within the inpatient clinical setting for students to complete the TNH assignment. Concept map incorporation promotes active student learning and provides a visual example of the interrelated Determinant of Health (DoH) categories that influence health outcomes. In addition, placing this TNH assignment in the community health clinical setting is vital to promote student critical thinking through the incorporation of transitional healthcare planning with DoH categories in the broader context of the community where people actually live.

Conclusion: Implementation of the TNH tool into the nursing curricula facilitates experiential learning for pre-licensure students to understand the role of nurses in promoting successful transitions. It is essential in the changing healthcare environment that nursing students are given tools to support successful transitions they can use when in clinical practice. The integration of competencies from inpatient clinical rotations and community health encouraged holistic transitional healthcare planning applicable to populations across the lifespan.