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Introduction

Transitional care planning is a patient-centered interdisciplinary process that is continuous throughout the care process. This undertaking incorporates diverse services aimed at increasing the overall health outcomes of the patients at the end of life. According to Naylor et al., (2017), transitional care advocates for patient’s safety and timed transition at all care levels. Of importance is the continuity and coordination of care during the end of life as there are critical decisions that must be made to support patient’s preferences and wishes. In most cases, critically ill patients are unable to make rational decisions concerning their end of life care. This necessitates inclusion of a surrogate decision maker either chosen by the patient or an attorney to make a decision on behalf of the patient. 

According to Le Berre et al., (2017), one of the impetus aspects in transitional care is open and clear communication with the stakeholders. This approach enables the patient and their families to understand the care preferences and promotes positive outcomes. Besides, this undertaking gives the patient autonomy concerning treatment modalities and preferences. The implications of these parameters to healthcare providers are that there is an overarching need to solve the barriers that may present an impediment to efficient transition. This paper will adopt a case study of Mrs. Snyder to develop a transitional care plan considering her current health condition. 

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Key plan elements and information needed

Several elements are critical to ensure effective transition of care for Mrs. Snyder. Besides, the care team must attain essential information to facilitate smooth transition for the patient. According to Sezgin et al.,(2020) transition of care for patients require six steps incorporating review of admission, patient assessment, conducting transition site contact, inter-professional collaboration, analysis of patient’s risk levels and linking the patient to primary care team. The transitional care model (TCM) advocates for close adherence to these protocols to ensure that patients attain optimum health outcomes due to safe transition (Morkisch et al., 2020). Patient screening enables care takers to collect evidence-based data that will enable them to make effective decisions during transitioning. This information is essential to determine the risk levels of the patient or potential of chronic illness. These elements also dictate to a significant degree the levels of relationships that will be created in the transition care process. As noted by McGilton et al., (2020), maintaining relationships with the patients will play a crucial role in facilitating effective implementation of care plan as everybody is aware of their scope in this perspective. Adopting these elements and information facilitates the success of transitional care. 

Importance of ach key elements

Examining the patient on admission allows determining the risk level. This aspect determines if a patient is at high or low risk and therefore, developing accompanying transitional care modalities. The rationality of conducting an in-depth patient assessment is informed by the need to develop support mechanisms according to patient’s needs (Rezapour-Nasrabad, 2018). Besides, conducting site contact for transition is an imperative aspect as it creates continuity in care process. In this aspect, the care takers understand the patient’s new home during discharge and care takers during handoff. 

The importance of involving the right personnel during transition is to facilitate delivery of professional care and patient’s safety. As cited by Le Berre et al., (2017), inter-professional collaboration in transitional care enables sharing evidence based information crucial to effective transition. In addition, it’s vital to depend on patient’s risk level to determine the accompanying level of risk. This undertaking allows the patient’s wish to be fulfilled in delivery of care. The importance of connecting patients to primary care givers is evident during handoff and transition. This process averts any case of disconnections and compromise of patient’s safety. 

Importance of effective communication

Transitional care includes considering the patient’s physical, medical, economic, mental and economic strengths and abilities and available support systems. This implies that coordination of these parameters is critical to allow for successful implementation of transitional care. In this aspect, effective communication plays a crucial role in this u